
Class 
Book. 






Copiglit'N?- 



I -3) I 



(KfFXRIGHT DEPOSm 



LATERAL CURVATURE OF THE SPINE 

AND 

ROUND SHOULDERS 



LOVETT 



BY THE SAME AUTHOR 

THE TREATMENT 

OF 

INFANTILE PARALYSIS 

SECOND EDITION 

125 Illustrations. Octavo. 
xi + 175 pages. Cloth $2.00 



P. BLAKISTON'S SON & CO. 

PHILADELPHIA 



LATERAL CURVATURE OF 
THE SPINE 

AND 

ROUND SHOULDERS 



■ ,, t;^^- BY - 

ROBERT W: LOVETT, M. D., Sc. D. 

BOSTON 

JOHN B. AND BUCKMINSTER BROWN PROFESSOR OF ORTHOPEDIC SURGERY, HARVARD UNIVERSITY 

MEMBER OF THE INTERNATIONAL SOCIETY OF SURGERY; MEMBER OF THE BRITISH, 

FRENCH, ITALIAN AND AMERICAN ORTHOPEDIC SOCIETIES; MEMBER OF THE 

SWEDISH SOCIETY OF MEDICINE; MEMBER OF THE ROYAL SOCIETY OF 

PHYSICIANS OF BUDAPEST 



FOURTH EDITION, REVISED 



WITH 172 ILLUSTRATIONS 



PHILADELPHIA ' 

BLAKISTON'S SON & CO 

1012 WALNUT STREET 



-1 









Copyright, 1922, by P. Blakiston's Son & Co. 



^-^^ 



PRINTED IN U. S. A. 
5Y THE MAPLE PRESS YORK PA 



CU68C120 



TO 

VITTORIO PUTTI 

IN TOKEN OF FRIENDSHIP AND WITH DEEP 
REGARD FOR HIS SCIENTIFIC ATTAINMENTS 



OCT -6 '22 



PREFACE TO THE FOURTH EDITION 



In revising this book it has been my intent to eHminate methods 
of treatment which have fallen into disuse or which have proved 
inadequate, and to lay more emphasis upon those which have stood 
the test of time. I have endeavored so far as possible to shorten and 
simplify those portions of the book which permitted it, and I have 
adopted the personal point of view in presenting doubtful matters. 

A good deal of new material has been added, although no radical 
advances in the treatment of scoliosis have been made in the last 
few years; but the great importance of mobilizing distorted spines 
constitutes, I believe, the most important change in the point of view. 

I believe that due acknowledgment of the work of others has been 
made; but if, in spite of every care, there has been any omission, 
I beg in this place to express my regret. 

R. W. LOVETT. 



VI 1 



PREFACE TO FIRST EDITION 



The successful treatment of lateral curvature of the spine cannot in 
the past be counted as one of the achievements of orthopedic surgery. 
The affection is not only intrinsically resistant to treatment, but the 
therapeutic measures employed have been on the whole largely 
empirical and have not been sufficiently correlated to its pathology 
and to the mechanism by which it is caused. In the last ten years, 
however, a good deal of progress has been made along new and prom- 
ising lines, by means of experimental and clinical work, the records 
of which He scattered through later medical Hterature. In the follow- 
ing pages I have attempted to bring together this literature and to 
add my own personal views and experience, in the hope of presenting 
the subject in English in a modern light and to call attention to the 
prospect offered of obtaining better results. That such a book is 
needed I have been led to infer from many inquiries in connection 
with this subject by physicians, medical students, and teachers of 
physical training. If I have devoted too large a part of the book to 
the question of treatment it is because of the scant attention paid to 
that part of the subject in most books dealing with deformities. 

The anatomical part of the work is from the Anatomical Depart- 
ment of Harvard University, and much of the clinical work is from 
the Scoliosis Clinic of the Children's Hospital, Boston. 

It is impossible to acknowledge my indebtedness individually to 
those of my colleagues and others who have helped me by contribut- 
ing material and other assistance. I should, however, express my 
obHgation to Professor Thomas D wight for his advice given in con- 
nection with the anatomical part of my work, for the liberal- supply 
of anatomical material with which he has provided me, and for 
criticising my chapter on Anatomy. To Miss Amy Morris Homans, 
Director of the Boston Normal School of Gymnastics, I wish to ex- 
press my indebtedness for assistance given in many ways; and to my 
assistants, Fraiilein Helene Seltmann and Miss W. G. Wright, for 
great help in preparing the hst of exercises. 

I have used freely the chapters on Pathology and Occurrence in 

the admirable article on ScoHosis by Schulthess of Zurich, recently 

pubhshed in Joaqhimsthal's "Handbuch der Orthopiidischen 

Chirurgie." 

Robert \V. Lovi:tt. 
Boston. 

ix 



TABLE OF CONTENTS 



Chapter ' Page 

I. History of Scoliosis i 

II. The Anatomy of the Vertebral Column and the 

Thorax 8 

III. The Movements of the Spine 29 

IV. The Mechanism of Scoliosis 43 

V. Description and Symptoms . . . . • 51 

VI. Examination and Record of Scoliosis 71 

VII. Pathology 83 

VIIL Etiology. 97 

IX. Occurrence 112 

X. Relation of Scoliosis to School Life 118 

XL Diagnosis 125 

XII. Prognosis 129 

XIIL Treatment * . . . 131 

XIV. Faulty Attitude 194 

Index 215 



XI 



LATERAL CURVATURE OF THE SPINE 
AND ROUND SHOULDERS 



CHAPTER I 
THE HISTORY OF SCOLIOSIS^ 

To write the history of scohosis one must start with the begin- 
nings of medicine and follow down through some 2500 years the 
course of an affection for many centuries classed with other cur- 
vatures of the spine, and considered, as they were considered, 
due to dislocation of the vertebras. One finds in this, as in most 
affections long recognized, that time brings about its identification 
as an entity, after which it gradually becomes separated from 
similar affections and is discussed by itself. 

The term "scoliosis" dates much farther back than the recogni- 
tion of the affection itself. (7/coXioco, from which scoliosis is derived, 
is a Homeric word meaning to bend or twist, and the term aKoXiccsLs 
was first used by Hippocrates, who lived four centuries before the 
beginning of the Christian era. His use of the word apparently was 
to designate a lateral form of the spinal curve supposed to be due to 
dislocation, the forward curve being called lordosis and the back- 
ward curve kyphosis. There were two other words in use at this time 
which have dropped out, and which are of no significance. 

Although the name scoliosis was given by Hippocrates, a very 
short extract from his works will show that he had little or no idea of 
what the condition was. After a description of posterior curvature 
of the spine, which is fairly accurate in a very rough way, he goes 
on: — ''In some cases the curvature of the spine is lateral, that is to 
say, either to the one side Or to the other, and most of such cases are 
connected with tubercles (abscesses?) within the spine, and in some 
the position in which they had beeii accustomed to lie cooperates 
with the disease . . . but these will be treated of among the 
common affections of the lungs." 

^"Geschicte und Behandlung der seitlichen Ruckgratsverkriimmung," 
Strassburg, 1885. 

Chlumsky: "Prispezky k Dejinam Skoliosy," Prag, 1910. 

I 



2 THE HISTORY OF SCOLIOSIS 

"Lateral curvatures also occur, the approximate cause of which is 
the attitudes in which these people He. These cases have the 
prognostics accordingly." 

Yet Hippocrates gave a very clear description of club-foot, which 
was well recognized by him, and although the splints advised seem 
rather inefficient, the treatment by moulding and retention was 
advocated. Patients with spinal curves, however, were tied by 
the legs to a ladder, and the ladder raised and then dropped to the 
ground, striking on one end, thus tending to straighten the spine, or 
such patients were put into an apparatus to make extension and 
pressure on the prominence. He adds as a further refinement of his 
treatment: — "It is also safe for a person to sit upon the hump while 
extension is being made, and raising himself to let himself fall down 
again upon the patient." He also suggests putting one foot on the 
hump or using a long wooden lever, but one finds no mention of any 
attempt at retention, and the reason for this is that all the treatment 
w^as based on the supposition that the affection was due to a dis- 
location, which demanded reduction only. 

For about 2000 years after Hippocrates, scoliosis attracted little 
attention and no advance was made. Paul of Aegina, 650 A. D., 
suggested bandaging to wooden strips in cases of curvature of all 
varieties, and Albukasis 500 years later announced that "no one 
could cure curvature to the side." 

And so one comes down through the centuries with no new fight 
to the time of Ambroise Pare, born in 15 10, and we find him where 
we left Hippocrates 2000 years before. I quote from his writings: 
"A dislocated vertebra standing forth and making a bunch is termed 
in Greek kyphosis, but when it is depressed it is called lordosis, but 
when the same is luxated to the right or left side it maketh a scoliosis, 
which, wresting the spine, draws it into the similitude of the letter S 
. . . Fluid and soft bodies, such as children, are very subject 
to generate this internal cause of defluxion. Thus nurses, while they 
too straitly lace the breasts and sides of girls so to make them 
slender, cause the breast-bone to cast itself in forward or back, or 
else the one shoulder to be bigger or fuller, the other more spare or 
lean. The same error is committed if they lay children frequently 
and long upon their sides, then upon their backs, or if in taking them 
up when they walk they take them only by the feet or legs and never 
put their other hand in their backs, never so much as thinking that 
children grow most toward their heads." Then follows a fair ac- 
count of the deformity, and the reduction of the dislocation is on the 



HISTORY 3 

same lines as advocated by Hippocrates, by extension and pressure 
by the hand or by lever. He suggested, however, the use of a padded 
iron corset, the illustrations of which are famihar, but still it was 
always a dislocation that was considered. It was to be treated by 
levers and great force, and the after-treatment played only a very 
small part. 

Among the various authors of the next hundred years one finds 
silence on the subject in most, such as Fab.ricius, Hieronymus and 
Vesalius, but here and there are flashes of light, mostly fantastic 
speculations as to etiology, but the affection was frequent, for 
Riolan, in 1641, stated that in France the girls carried as a rule the 
left shoulder higher than the right, and that one could hardly find 
a case where the shoulders were rightly constructed. His specula- 
tions as to etiology were much the same as those of the nineteenth 
century, namely, the use of the right arm and the wearing of stiffened 
corsets. The first autopsy of ascoliotic case was reported in 1646 by 
Fabricius Hildanus, without apparently clearing up the matter. 
Glisson, writing of rickets, which he named rachitis, in 1660, described 
the spinal curves due to it, and suggested for this indiscriminate 
treatment gymnastics or suspension, but Glisson's suspension was 
from axillae, head and hands, by which the children were slung and 
allowed to play in the air, which he adds "they did with great 
enjoyment." The head sling proper dates from Nuckius in 1696, 
and was devised for the treatment of wry neck. 

From this time until the time of Andre in 1741, one cannot see 
that any author contributed much to progress, although it is evident 
that whalebone corsets were coming into use as a method of treat- 
ment, originating with Jungken in 1691, and the mention of scoliosis 
is more frequent than in the preceding century, but never apparently 
differentiated clearly from other curvatures. 

Andre was a man of originality, the inventor of the term " ortho- 
pedic," and he wrote more fully of spinal curves than his predecessors. 
He condemned high heels and blamed them and bad sitting positions 
for much of the faulty attitude. Among causes for spinal curves he 
mentioned hemorrhoids, which were so painful that the child could 
not sit squarely, and he called attention to the important fact that 
as a child grew the clothes must be made larger. He suggested 
gymnastics and apparatus as a means of treatment. 

Taking it altogether the middle of the eighteenth century, that is 
to say, the time of the beginning of the American Revolution, was a 
time of considerable activity and some little progress in the history 



4 THE HISTORY OF SCOLIOSIS 

of scoliosis. Andre was the first to group deformities together and 
to give a name to the specialty. His directions about treatment were 
vague, but he recognized in bow legs at least that the same means 
must be taken to straighten them as were adopted to straighten the 
crooked stem of a young tree. He advocated friction of the de- 
formed parts and their gradual restoration by manual extension, 
pressure and localized movement. A very distinct step at about this 
time was made by the classical work of Percival Pott, who published 
in 1779, his essay on "The Palsy of the Lower Limbs in Consequence 
of a Curvature of the Spine." In this work he took out of the un- 
classified group of affections known as curvatures of the spine, those 
posterior curves caused by spinal tuberculosis. He stated with 
regard to the paralysis "that none of those strange twists and de- 
viations which the majority of European women get in their shapes 
from the very absurd custom of dressing them in stays during their 
infancy, and which put them into all directions but the right, ever 
caused anything of this kind, however great the deformity might 
be." His description of spinal tuberculosis was so accurate that it 
immediately identified posterior curvature as a carious or scrofulous 
disease of bone and not as a dislocation, and thus cleared the field 
for the recognition of scoliosis as an entity. 

About this time scoliosis was becoming more clearly defined. 
Autopsies were being performed, and it was being recognized that it 
was not to be classed and treated with the , posterior curvatures. 
This came not only from the work of Pott, but was gradually coming 
in from all sides, and apparatus of various kinds began to be devised. 
The iron cross of Heister, invented in 1700, began to be displaced 
by apparatus more of the modern type, and the corset of Maguy,. de- 
vised in 1762, would find a sale to-day in the instrument shops; but 
the greatest impetus was given by the apparatus of Levacher in 
1768, which consisted of a whalebone corset to which was affixed 
jury mast and a head sling. 

Although the period at the middle of the eighteenth century, as 
has been said, was one of considerable activity and progress in the 
development of scoliosis, at about this time there began and lasted 
for over a hundred years, the dreariest and most confusing period 
in the history of the affection. The theorist and the apparatus in- 
ventor went mad, and every form of device appeared. Braces and 
corsets infinitely complicated, worse than useless, appeared by the 
dozen. Beds especially constructed, chairs, slings, swathes, belts, 
levers and the like, all found their advocates, and theories as to the 



HISTORY 5 

causation also ran riot, but on the whole the invention and elabora- 
tion of apparatus held the center, of the stage, and one heard but 
Httle of gymnastics. 

It is difficult, to trace the origin of the gymnastic treatment of 
scoliosis, for it had existed from an early time. Even as early as 
Glisson a system of gymnastics was clearly formulated, and appar- 
ently gymnastic treatment was not at that time by any means 
new. Sydenham, 1624-1689, wrote "If anyone knew of the values 
of friction and exercise and could keep his knowledge secret he 
might easily make a fortune," and "Fuller's Medicina Gymnastica," 
published in 1704, was followed by a similar work by Tissot in 1781, 
and by Jahn and others, who worked with energy to spread German 
gymnastics. A very decided impetus came from Sweden from Henry 
Ling, who died in 1839, and who founded a system of gymnastics 
known as the Ling system or Swedish movement treatment. An 
institute under the supervision of the Swedish government was 
established in Stockholm, and Ling was its first president. A paper 
advocating gymnastic treatment was published by Langgard in 
1868, and books and monographs followed in rapid succession. 

Thus toward the middle of the nineteenth century, at the close 
of the hundred-year period which has been spoken of as dreary and 
demorahzing, gymnastic treatment began to crowd apparatus treat- 
ment and to absorb some of the attention previously given wholly 
to mechanical treatment. From this point gymnastic treatment 
has increased in prominence until it is fair to say that to-day it 
constitutes the bulk of the scoliosis treatment in America. 

Shortly after the middle of the nineteenth century there began 
what seems to be the first real progress that had been made in 
the treatment of structural scoliosis. To one who reads the history 
of the past the impression is left that up to this time the etiology 
had been the subject of a great deal of loose and irrational theory, 
that the recognition and identification of the affection had been 
delayed for centuries, and that all treatment up to this time had 
been, as we see it to-day, ineffectual and comparatively useless. 

In 1878, Lewis A. Sayre published a book on "Spinal Disease and 
Spinal Curvature," in which he advocated their treatment by 
self-suspension and a plaster-of-Paris jacket. Self-suspension 
he credited to Dr. Benjamin Lee of Philadelphia and Prof. Mitchell 
of Philadelphia. He advocated the application of a plaster-of- 
Paris jacket in suspension, with the heels hfted from the ground, and 
he claimed for them nothing more than support in an improved posi- 



O THE HISTORY OF SCOLIOSIS 

tion. The jackets were removable, and exercises were done daily. 
The treatment was too mild to be effective, but it contained appar- 
ently the germ of the modem progress in the treatment of the affec- 
tion. The use of plaster-of-Paris jackets thus became more or less 
common in cases of Pott's disease as well as of scohosis, and the work 
of Calot in 1896. who advocated at that time the use of forcible cor- 
rection in the treatment of Pott's disease, suggested the use of more 
force than had been previously used in the correction of lateral 
curvature. Schanz published, in 1900, an account of an efficient 
technic for the appHcation of jackets in suspension, and reported 
results in 1902. In 1901, the author reported results and described 
a technic where the patient lay on the face during the apphcation, 
and there were other papers written at about this time, but the 
great impetus to the treatment by forcible correction came from 
Wullstein. who read a paper at the International Congress in Paris 
in 1900, and who pubhshed his experiments, methods and results 
in 1902. He showed experimentally that bony scohosis could be 
produced in young dogs who were kept for some months in a bandage, 
inducing a lateral cun^e of the spine, and by the use of plaster-of- 
Paris jackets apphed to the scohotic patient in an improved position, 
induced by the use of great traction and lateral pressure, he secured 
results that were better than any previously reported. The work 
attracted much attention, and markedly modified the whole point 
of \iew with regard to forcible correction, which began to gather a 
body of adherents whose number has steadily increased. 

The method of Wullstein has been extensively modified. Jackets 
have been apphed with the patient on the face, on the side, on the 
back, -with the spine flexed, with the spine h}-perextended, on simple 
hammocks, and in comphcated apparatus, but the principle demon- 
strated as effective by Wullstein and carefully elaborated by him 
has not been modified, namely, crowding the spine into an improved 
position and holding it there during as long a period as seems 
practicable, and for this purpose using plaster-of-Paris. 

There have been from time to time pieces of work elaborated 
which have modified our point of \-iew with regard to the etiolog}' 
of scohosis. and have to a certain extent influenced our treatment. 
The work of Bohm in 1906, called our attention to the frequency of 
congenital maHormations as a cause of scohosis, and immediately 
transferred many cases from the class of acquired to the class of 
congenital scohosis. Subsequent work by Bohm and by others has 
laid stress on the fact that the occurrence of severe scohosis is prob' 



HISTORY 7 

ably due to congenital conditions or to abnormalities of bone, and 
that too much importance must not be allowed to the former ideas 
that severe scohosis was caused by assumed bad posture, carrying 
burdens, bad school positions, etc. 

The discussion in the German Orthopedic Congress in 1910, 
with regard to school life as a cause of severe scoliosis was most 
illuminating, and the majority of the writers who participated were 
of the opinion that although the school might cause a postural 
scoliosis it was very doubtful if it could be accepted as a routine 
cause of severe scoliosis. 

The monumental work of Schultess in the Joachimsthal Hand- 
buch fiir Orthopadische Chirurgie formulated, clarified and illus- 
trated our knowledge of scoliosis. 

What the prevailing treatment of scoliosis is to-day cannot be 
stated in a few sentences. Some men advocate one method, some 
another. To those of us who beUeve that forcible correction has ac- 
compHshed more than any other treatment and will accomplish more 
in the future, the development of the real treatment of scohosis 
dates from 1875. To those who beHeve that the gymnastic treat- 
ment of scoliosis is the best, and that forcible correction is wrong, the 
progress in the matter of scoliosis starts with Hippocrates and comes 
down in a wavering and discouraging line from that date until the 
present, with a better knowledge of the affection on the whole, with 
probably some more effective gymnastic technic, but without any 
very great advance within the last hundred years in the line of 
efficiency. 



CHAPTER II 

ANATOMY OF THE VERTEBRAL COLUMN AND THE 

THORAX 

The spine is a flexible weight-bearing column made up of a series 
of vertebrae separated from each other by twenty-three intervertebral 
discs and connected with each other by ligaments and muscles. In 
early hfe the vertebrae are thirty.-three in number. The upper 
twenty-four, which remain separate throughout life, are distin- 
guished as true, movable, or presacral vertebrae. In the adult 
the lower nine are fused into two masses to form the sacrum and the 
coccyx, and are called the false, fixed, or immovable vertebrae. The 
spine forms the central axis of the skeleton, situated in the median 
plane of the body and posterior part of the trunk. By the term 
"the spine" is generally understood the part of the column above the 
sacrum. 

In shape the spinal column is roughly pyramidal, the columm of 
vertebral bodies tapering from below upward, and after early in- 
fancy it shows four curves, two anterior and two posterior, in the 
sagittal or median anteroposterior plane. These are called the 
physiological curves, which will be discussed later in the chapter. 

The spine encloses and protects the spinal cord, and provides, with 
the sacrum, thirty-one pairs of intervertebral foramina through 
which the spinal nerves emerge. It serves by its intervertebral 
discs to diminish the jar of walking. 

The total length of the spine is given as follows by different 
authors: Cunningham, 70 to 73 cm.; Morris, 70 cm.; and Krause, 72 
to 75 cm. (along the curves), which is 45 per cent, of the body-length. 
The relative length of the separate regions is shown in the following 
table : 

D WIGHT 3 . 
CUNXINGHAMl M0RRIS2 BeAUNOIS !MaLES FeMALES 

Cervical region 13-14001. 12.5 cm. 10.8 cm. 13.3 cm, 12.1cm. 

Dorsal region 27-29 cm. 27.5 cm. 27.0 cm. 28.7 cm. 26.5 cm. 

Lumbar region 12-15 cm. 17.5cm. 16.8 cm. 19.9 cm. 18.7cm. 

1 Cunningham: "Text-book of Anatomy," Macmillan, 1902. 

2 Morris: "Human Anatomy," Blakiston, 1903. 

3 Dwight: "Medical Record," Sept. 8, 1894. 



ANATOMY 9 

It is frequently stated that the length of the spine in different in- 
dividuals is pretty constant, but Dwight's figures show rather a wide 
variation. In fifty-six male spines the longest was 69.8 cm. and the 
shortest 56.4 cm. 

In a straight line, the column measures in men from 66 to 70 cm., 
and in women from 66 to 69 cm., with an average of 67 cm. (Krause). 
This height is approximately 40 per cent, of the total height of the 




Pig. I. — The Spine seen from the 
Side, Showing the Physiological 
Curves. — (Warren Museum.) 



Fig. 2. — The Spine Seen from the 
Front. — {Warren Aluseum.) 



individual. In the fetus and young child the column forms a greater 
proportion of the body-length. At puberty the more rapid growth 
of the rest of the body overtakes that of the spine, which completes 
its growth between the ages of twenty-three and thirty-one years. 



lO ANATOMY OF VERTEBR.\L COLUMN AND THORAX 

The percentage of total length of the individual occupied by the 
spine without the sacrum is given for different ages by Moser as 
follows : 

Per Cent, of 
Vertebral Col- 
Vertebral Col- umn to Body- 
Age Body-length umn Length Length 

o 50 192 38.4 

3 86 31.7 36.8 

5 112 35 .30 

II 138 41 29.7 

14 152 44 28.9 

IS3^ • 162 45 28.1 

Adult 167 57 34.1 

The spine is divided into three regions corresponding to the parts 
of the trunk with which it is connected: (i) The cervical region ; (2) 
the thoracic or dorsal region; (3) the lumbar region. 

The cervical region comprises the upper seven vertebrae, including 
the atlas and axis; the thoracic, twelve vertebrae; and the lumbar, 
five vertebrae. The lower part of the spine may be spoken of as the 
posterior end, while the upper part may be called the anterior end 
of the column. The middle of the spine is placed at the eleventh 
dorsal vertebra. 

IXTERVERTEBR.\L DISCS 

The bodies of the vertebrae, from the second cervical to the sacrum, 
are separated from each other by the intervertebral discs lying 
between them, twenty-three in number, and are also firmly held 
together by ligaments to be spoken of later. The discs correspond 
in size and shape to the horizontal surfaces of the bodies of the verte- 
brae between which they are found, but they project slightly beyond 
the edges of the vertebrae. The sum of the heights of all the discs is 
greatest through the middle portion, next largest through the ante- 
rior borders, and least through the posterior borders. Singly the 
discs vary in height in the different regions of the spine. They are 
higher anteriorly in the cervical and lumbar regions and posteriorly 
in the dorsal region. The ratio of the height of the discs to the 
height of the bodies varies according to different authors. Weber 
gives the ratio of the average height of all the discs to the average 
height of all the vertebrae, not including the sacrum, as i : 5. Accord- 
ing to the same author the ratio of the height of all the discs through 
the centers to the height of the vertebral column, represented by a 



PHYSIOLOGICAL CURVES 



II 



perpendicular from the highest point of the atlas to the sacrum, is 
as 1:4. 

V m h ^^^ influence of the discs in the formation of 

the physiological curves of the spine is shown by 
the two curves in Fig. 4. Curve (A) is formed by 
the bodies and the discs together, and curve (B) is 
the result obtained by placing the bodies one upon 
the other, forming a long curve with convexity 
backward, greatest in the lower dorsal region. The 
convexity of the thoracic spine is flattened in the 
upper part, and the lumbar and cervical physi- 
ological curves almost completely disappear when 
the discs are removed. 



Fig. 3. — Lines Rep- 
resenting THE Sum 
OF THE Thickness of 
THE Intervertebral 
Discs. — (Pick.) 

V, At the front bor- 
der; m, in the middle 
of the disc; h, at the 
posterior border. 



Fig. 4. — Curves of the Vertebral Column. — (Fick.) 
A, With intervertebral discs; B, without intervertebral discs. 



The discs become smaller and harder with 
age, shrinking to a greater extent where they are 
thickest than in the region where they are thin. 
For this reason the curve of the spine in late 
middle life shows an increase in its dorsal 
backward curve, especially towards its upper 
part and the head is carried forward and its 
spinal curve approaches that shown in the figure 
(B) to a varying extent, and the bowed back of 
old age is substituted for the upright attitude 



12 



ANATOMY OF VERTEBRAL COLUMN AND THOR-\X 



with a lumbar forward curve which is largely due to the influence 
of intervertebral discs. 

The discs are very firmly attached to the bodies of the vertebrae, 
and are also attached to the anterior and posterior common hgaments 
of the spine. The intervertebral discs thus furnish a connecting 
structure of great strength between each two vertebrae, and at the 
same time furnish each what amounts to a ball-and-socket joint on ac- 
count of the incompressible fluid pulp in the center of each disc 
between each two vertebral bodies, except of course the first two 
cervical. 



LIGA^IEXTS OF THE SPIXE 

In addition to the connection of the bodies by means of the inter- 
vertebral discs the vertebrae are bound together by hgaments which 
serve to limit movement between them and contribute stabihty and 
strength to the column. Ligaments are composed of white fibrous 




^^^ 



Fig. 5- 



-Median Section of a Portion of the Adxjlt Lumbar Vertebral Column, 
The Right Half Seen from the Left. — {Pick.) 



tissue, the strongest tissue in the body, highly elastic, but non- 
extensible. Two of the spinal ligaments, the ligamentum nuchas 
and the subflava, form exceptions to this statement, being made up 
almost entirely of yellow fibrous tissue. 



SACRO-ILIAC JOINT 



13 



SACRO-ILIAC ARTICULATION 

The strong joint between the sacrum and the ihum through which 
the whole body- weight is transmitted is a synchondrosis. These 
transmit the weight of the spine to the pelvis and thence to the legs. 
They are ear-shaped articular surfaces of irregular contour, in general 
vertical in direction, containing some synovial membrane and heavy 
ligamentous bands. That they permit some motion is well estab- 
lished, but this amount of motion is small. Klein^ found that 25 
kg. of force applied to the 
symphysis with the sacrum 
fixed produced a rotation of 
the ilia on the sacrum, which 
on the average, measured by 
the excursion of the sym- 
physis, was 3.9 mm. in man 
and 5.8 mm. in woman. 
Measured at the sacro-iHac 
joint this excursion was 
about one-sixth of this 
amount; that is, in man the 
average amount of motion 
in the sacro - ihac joint, 
measured at the posterior 
part of the joint, was about 
0.6 mm. These joints are 
protected against much 
motion by intra- and extra- 
articular Kgaments of the 
heaviest variety. In front 
of them lie the lumbosacral 
cord and sacral plexus. 




THORAX 



Fig. 6. — Model of the Spine Showing the 
Anatomical Relations, Especially the Dis- 
position of the Soft Parts in the Lumbar 
Region. — (Warren Museum.) 



The thorax is a bony cage 
containing the principal organs of circulation and respiration. It 
is formed by the thoracic vertebrae, the ribs, the costal cartilages, 

1 Klein: Ztschr. f. Geburt. u. Gynak., 1891, xxi. Watcher: "Verhandl. d. 
deutsch. Gesellsch. f. Gynak.," Bonn, 1891. Strasser: "Lchrbuch der Muskel 
und Gelenk Mechanik, Bedin," 1913. Dieulafe and St. :\lartin, C. R.: "Assn. 
d. Anat.," 14 Reunion Revues, 191 2. 



14 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



and the sternum. The ribs, twelve on each side, form a double 
series of narrow, curved, flattened bones attached posteriorly to 
the thoracic vertebrae. They extend at first outward, and then 
forward, inward, and downward toward the median line anteriorly. 
The seven upper ribs, called the true, sternal, or vertebrosternal 
ribs, are attached directly to the sternum by the costal cartilages 
anteriorly. The lower five ribs are called false or asternal ribs; 
the eighth, ninth, and tenth are distinguished as vertebrochondral, 
as they are anteriorly indirectly united to the sternum by the 
cartilage of the rib or ribs above; the eleventh and twelfth are called 
floating ribs, as their anterior extremities are loose in the abdominal 
wall. The ribs increase in length from the first to the seventh or 
eighth, decreasing from the eighth to the twelfth. They are ap- 
proximately parallel with the exception of the eleventh and 
twelfth, which slant somewhat more downward. 




Fig. 7- — Horizontal Section of Thorax at Seventh Dorsal Vertebra Showing the 
Position of the Vertebral Bodies. — (From Braun's Atlas-Corning.) 



It must be remembered that ribs are lower at their front ends than 
at their vertebral connection, so that if it is desired to rotate a verte- 
bra by pressure on a rib, the rib horizontally opposite the vertebra is 
not to be chosen. It has been shown^ in the cadaver (i) that rota- 
tion of vertebrae may be produced, when the extremities of the spine 
are fixed, by pressure upon any of the intermediate ribs; (2) that the 
vertebrae attached to the ribs on which pressure is made are the 
most affected; (3) that the rotation never equals the rib excursion; 
(4) that the most effective points for pressure or counterpressure are 

^ Keene: "Amer. Jour. of.Orth. Sur.," July, 1906, page 69. 



SHAPE AND BOUNDARIES OF THE THORAX 



IS 



as far as possible from the midline anteriorly and posteriorly except 
on the lowest four ribs. 

STERNUM 

The sternum or breast-bone is situated in the median line of the 
trunk, completing the thoracic cage anteriorly. The sternum is a 
fiat bone, and as a whole, it lies directed obliquely forward and 
downward. It consists of three parts — the manubrium sterni, the 
gladiolus, and the ensiform cartilage or xiphoid 'process. 

SHAPE AND BOUNDARIES OF THE THORAX 

In shape the thorax is somewhat conical, larger behind than in 
front and compressed antero-posteriorly.. The posterior wall is 
formed by the thoracic vertebrae, and by the ribs, from their heads 
to their angles, and is convex vertically and horizontally. Laterally 
the cage is formed by the shafts of the ribs; it is somewhat convex 
vertically and sharply convex from before backward. The anterior 



Anterior radi- 
ate or stellate 
ligament 

Costo-central 
synovial sac 



Fibrous ring of in- 
tervertebral fibro- 
cartilage 

Pulpy nucleus of 
intervertebral fibro- 
cartilage 




Middle costo 
transverse liga- 
ment 



Costo-transverse synovial sac 



Posterior costo-transverse ligament 



Fig. 8. 



-Horizontal Section through an Intervertebral Fibro-cartilage and the 
Corresponding Ribs. — (Morris's "Anatomy.") 



surface, slightly convex and directed forward and downward, is 
formed by the sternum and the costal cartilages. The plane of the 
superior opening or inlet of the thorax is inclined forward and 
downward, showing a greater obHquity in women than in men. 



1 6 ANATOMY OF VERTEBRAL COLUMN AND THORAX 

The inferior border of the thoracic cage is formed by the tweKth 
thoracic vertebra, the lower borders of the twelfth rib, and by two 
curved lines, extending from the anterior extremities of the last rib 
to the inferior angles of the gladiolus, touching the anterior extremi- 
ties of the eleventh rib and the costal cartilages of the tenth, ninth, 
and eighth ribs. The angle formed by these lines is known as 
the subcostal angle. The inferior surface of the thorax is directed 
forward and downward. 

MUSCLES OF THE SPINE AND THORAX 

The general grouping and arrangement of the muscles in their 
relation to the spine has an important practical bearing on scoliosis. 
The spine lies toward the back of a more or less cylindrical muscular 
tube of which the abdominal muscles form the front. Of muscles 
directly attached to the spine there are two varieties: (i) muscles 
running from one part of the spine to another part and to the head; 
(2) muscles running from the spine to the pelvis or shoulder-girdle. 
The abdominal muscles by their attachment to the thorax, which is 
comparatively rigid, have an action on the spine. By the combined 
action of these three the erect position is maintained, or any variation 
from it is accomplished. 

In making a side flexion of the spine from the erect position, for 
example, no one muscle or group of muscles is alone active, but it 
imphes a concerted and coordinated action of all the groups men- 
tioned, as well as of the muscles of the lower extremities, to keep the 
balance and perform the bending. The maintenance of the spine 
in the upright position by the muscles has been compared to the way 
in which a flagstaff is held upright by stays reaching from the top of 
the staff to the ground. Although there is no one muscle running 
from the head to the pelvis, there is a continuous set of muscles 
supplementing each other's action. For example, in the anterior 
line the sternomastoid runs from the skull to the front of the top of 
the thorax, the sternum connects the upper and lower ribs and forms 
a rigid piece, and the lower thorax is connected with the pelvis by 
the rectus abdominis muscle. In the back the continuity of muscu- 
lar action is shown by the fact that before the top insertion of the 
longissimus dorsi has been reached, the complexus and transversalis 
cervicis have begun. The whole conception of muscular action in its 
relation to gymnastics is simphfied by remembering the continuity 
of the muscular tube from the head to the pelvis. 



MUSCLES 



17 



The thorax represents a comparatively fixed cage inserted in a 
structure quite movable above and below it; muscles attached to the 
thorax are therefore indirectly attached to the spine. The compara- 
tive rigidity of the thoracic part of the spine is due to the fact that 




Fig. 9. — G. Herman Meyer. The Two 
Oblique Muscle Pulls. — (Feiss.) 
On the left the descending oblique, a. 
External intercostals; b, descending ob- 
lique or externus abdominis. On the 
right the ascending oblique muscle pull. 
c, Descending oblique or internus abdomi- 
nis; d, internal intercostals; e, scalenus 
colli; /, cremaster. 




Fig. 10. — G. Herman Meyer. The 
Scheme of the Torso Musculature 
Indicating the Direction of the 
Various Muscle Pulls. — (Feiss.) 

a. Posterior longitudinal muscle pull 
(sacrospinalis) ; b, anterior longitudinal 
muscle pull; c. oblique descending muscle 
pull;d, oblique ascending muscle pull; e, 
transverse muscle pull. 



the majority of the ribs are attached posteriorly between two 
vertebrae, that they pass forward to be also attached to the sternum, 
and that the whole structure is one well calculated to prevent 
physiological side bending or extensive forward or backward motion 
in that region; the cage must therefore largely move as a whole. 

It has been pointed out that the dorsolumbar junction is a dividing 
point for important muscular origins and insertions above and below 
2 .^ 



i8 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



it, e.g., the psoas muscles originate largely below it and the trapezius 
above it, and that it forms a weak and movable part of the spine for 
this reason. More important than this is the fact that muscles 
connecting the thorax and pelvis will move the spine where the rigid 





Fig. II. — G. Herman Meyer. 
The System of the Sacrospinalis. 
—{Feiss.) 

a, Spinalis; b, longissimus dorsi; c, 
transversalis cervicis; d, trachelomas- 
toideus; e, ileocostalis; /, ascendens 
cervices; g, ileolumbalis (hinder por- 
tion of m. quadratus lumborum 
Auct.); h, obliquus capitis inferior; 
i, obliquus capitis superior; k, rectus 
capitis posterior major; /, rectus 
capitis posterior minor. 



Fig. 12. — G. Herman Meyer. 
Anterior Longitudinal Muscles 
OF THE Trunk. — (Feisi.) 

a, Sternocleido-mastoideus; 6, rectus 
abdominis; c, pyramidalis. 



dorsal region changes to the movable lumbar region and that a large 
number of muscles will therefore express their contraction by motion 
at the dorsolumbar junction. A similar weak and movable part of 
the spine is said to exist at the cervicodorsal junction, where impor- 
tant muscles (splenius and rhomboids) have a dividing point. 




NERVE-SUPPLY 1 9 

MOTOR SENSORY I REFLEX 



Sterno-mastoid 
Trapezius 

Diaphragm 

1 Serratus 
i / Shoulder 

Arm 

Hand 

(u-lnar lowest) 



Intercostal 
muscles 



Abdominal 
muscles 



Flexors, hip 



Extensors, knee 
Adductors ] hip 



Abductors 



Extensors( ) 
Flexors, knee (?) 

Muscles of leg 
moving foot 

Perinaeal and anal 
muscles 



Neck and scalp 
Neck and shoulder 

Shoulder 

Arm 

Hand 



Front of thorax 
Xiphoid area 



Abdomen 
(Umbilicus loth)! 



Buttock, upper 
part I 



Scapular 



Epigastric 



Abdominal 



] Groin and scrotum , ] 
/ (front) _ ' 

' outer side ; \ Cremasteric 



Thigh 



front 



nner side 
Leg, inner side | 

Buttock, lower 
part 



Back of thigh 

Leg 

and 



foot 



except in- 



ner part 



Perinaeum and anus 



Skin from coccyx 
to anus 



Knee-joint 



■ Gluteal 

Foot-clonus 
Plantar 



Pig. 13. — Diagram and Tabu;: Showing the Approximate Relation to the Spinal 
Nerves of the Various Motor, Sensory, and Reflex Fi'nctions of the Spinal Cord. 
(Arranged by Dr. Gowers from anatomical and pathological data). — (Morris's "Anatomy.") 



20 ANATOMY OF VERTEBRAL COLUMN .AND THORAX 

NERVE-SUPPLY 

The spinal nerves emerge from the spmal canal through the mter- 
vertebral foramina and are distributed to the integument and mus- 
cles all over the body. Eight are cervical nerves (the first passing 
the atlas), twelve dorsal, five lumbar, five sacral, and one coccy- 
geal. Each nerve is formed by the union of two nerve roots, which 
occurs outside of the spinal cord and just inside of or at the interver- 
tebral foramen. The anterior, motor, or efferent fibers come from 
the cells of the anterior horn of the cord; the posterior, sensory, or 
afferent fibers emerge from the cells of the posterior horn on the same 
side of the cord. The nerve formed by these two roots on leaving 
the intervertebral foramen divides into an anterior and posterior 
branch, each with motor and sensory fibers. The posterior divisions 
are small and supply the skin and muscles of the back. The anterior 
divisions are distributed to the neck, the front and sides of the trunk, 
and to the extremities. Each anterior di\'ision is connected with 
a plexus, ganglion, or nerve of the sympathetic system. 

EVOLUTION OF THE SPINE 

The history of the spine in its evolution is of interest. In the 
Clyclostomata the vertebral column consists of a -non-segmented, 
homogeneous, cartilaginous rod. Articular processes first appear 
in the Rays and Teleostei. The backbone of the lower fishes con- 
sists of a series of bony discs bound together by elastic intervertebral 
discs. It would seem from the history of the spine as if articular 
processes developed concomitantly with the elaboration of structure, 
and as if they were incidental to its use rather than factors deter- 
mining of themselves its types of motion. 

As will be mentioned in a later section, the human spine, from 
an evolutionary point of view, is practically the quadruped spine set 
on end, a matter which has a distinct bearing on its weaknesses 
as an upright supporting column. 

OSSIFICATION 

The ossification of a vertebra occurs from three primary centers, 
one for the body and one for each lateral mass. These appear in the 
sixth week, and iu the cervical region the lateral centers are the first 
to appear, while in -the dorsal region the one for the body is the first 
seen. The center for the body is often double in appearance if not 
in realitv. The centers for the lateral masses are found near the 



PHYSIOLOGICAL CURVES 21 

bases of the articular processes and from them form the pedicles, 
laminae, articular processes and a large part of the transverse and 
spinous processes, the bodies of the vertebrae forming from the other 
center. The vertebral epiphyses serve to assist in the formation of 
joints, to provide for the attachment of ligaments and tendons, and 
to increase the development in length of the bone of which they form 
a part. At about puberty appear five other secondary or comple- 
mentary centers, one at the tip of the spinous process, one at the tip 
of each transverse process, and one at the upper and one at the lower 
surface of each body, occurring as a flat meniscus at about the seven- 
teenth year and uniting to the vertebral body a few years later 
(twentieth year). Inasmuch as vertebral growth occurs at each of 
these epiphyses, this comphcated method of ossification is important 
because the injury or disease of one of these epiphyseal lines might 
lead to serious bony deformity of the vertebra (Figs. 14 and 15). 

ELASTICITY OF SPINE 

The spinal column is capable of some movement in all directions. 
The elasticity of the intervertebral discs is such that the ball-and- 
socket joint between each two vertebrae allows motion between them 
in any plane or direction until Hmited by bony contact and Hgamen- 
tous or muscular tension. It also allows rotation to occur between 
two separate vertebrae in an approximately horizontal plane. Bone 
is slightly comipressible,. but this is not a factor of importance in con- 
tributing to vertebral flexibiUty. 

In childhood the vertebrae are largely cartilaginous, and the in- 
creasing proportion of bone, along with the diminishing proportion of 
cartilage, causes a decrease of flexibility from youth to adult age, 
aside from the fact that the flexibility of all joints is greater in youth. 
With old age the capability of movement of the spine is greatly les- 
sened on account of the atrophy of the intervertebral discs. 

PLANES OF THE BODY 

The planes of the body will be frequently spoken of and should be 
defined. The frontal plane is a vertical and transverse one. The 
sagittal or antero-posterior plane runs in the antero-posterior axis. 
The term horizontal plane is self-explanatory. 

PHYSIOLOGICAL CURVES (ANTERO-POSTERIOR) 

The physiological curves, so called, are antero-posterior curves 
and are important. They are three in number. 



22 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



The dorsal (backward) curve is the first to become evident, and 
was found present in 86 per cent, of normal children under one year 
old when lying on the face and in 99 per cent, of children over one 
year old. In children under six months this backward convexity 
included the lumbar region, but after this age it did not as a rule,^ 
the lumbar curve then occurring at the expense of the dorsal curve. 

The lumbar (forward) curve in lying showed frequently after the 
age of one year and in a very large majority of cases after the age 
of three years. The lumbar curve when it formed took the place 
of part of th^original backward dorsal curve and was more marked 

Epiphyseal plate or disc 



Mammillary tubercle 
Transverse process 
Spinous process 




Epiphyseal plate or disc 



Fig. 14. — Lumbar Vertebra at the Eighteenth Year with Secondary Centers. — 
{Morris's "Anatomy.") 

in standing than in lying. In standing it was present after the age 
of two years in a very large majority of cases, the exceptions being 
usually in children under three who had not walked. The lumbar 
curve in childhood is obliterated in a sitting position, only four chil- 
dren of those examined between the ages of nine and thirteen showing 
such a curve in the sitting position. 



Lamina 
Suture 

Pedicle 

Neuro-central suture 
Centrum 



Fig. 15. — Ossification of the Fifth Lumbar Vertebra. — {Morris's "Anatomy.") 

The cervical (forward) curve could not be accurately determined 
in either standing or lying in the youngest children, but after the age 
of fourteen months this curve was observed in standing. 

^Lovett, Davis, and Montgomery: "Arch, di Ortopedia," 1906, v and vi, 
page 372. 




PHYSIOLOGICAL CURVES 23 

In the adult, the part played by the bodies of the vertebrae and the 
discs in producing the physiological curves is shown by the following 
table. 

Difference between the Sums of the Anterior and Posterior Borders 

Vertebrae Discs 

Cervical region. . 1.3 mm. 7 . 8 mm. 

Dorsal region 13 • 3 mm. 9 . 2 mm. 

Lumbar region 6.7 mm. 21,1 mm. 

The cervical curve is formed principally by the intervertebral discs. 
It is a fairly mobile curve, and may be straightened by suspension. 
The dorsal curve is formed chiefly by 
the bodies of the vertebrae; it is a rigid 
curve and cannot be obliterated. The 
lumbar physiological curve is produced 
mainly by the greater anterior height of 
the intervertebral discs and is therefore 
mobile. 

A slight physiological lateral curve 
convex to the right has long been recog- 
nized in the spine. It has been attribu- 
ted to the pressure of the aorta on the 
vertebral bodies, to excessive use of the 
right side of the body in certain 
occupations, and to right-handedness. 

The almost constant occurrence of the 

curve indicates a common cause, which 

is most probably aortic pressure. The ^ ^ 

asymmetry extends from the fifth dorsal ■^" 

to the second or third lumbar vertebra. 

The body of the fifth dorsal vertebra .-^mPf 

is flattened on the left side, and the 

discs above and below are similarly Fig. 16.— Section of the spine 

re J 1 n^i • r 1 '/ O^ -^ New-BORN InF.\NT. 

artected. ihere is a groove irom 1^2 

to 2 cm. broad passing downward in a spiral direction, following 
the course of the aorta, to the anterior surface of the second or third 
lumbar vertebra. The discs between these vertebrae are usuallv 
less projecting than the others, and if the cutting away of the 
vertebra cannot be seen the flattening of the disc is alwa\-s apparent.^ 

^Pere: "Les courb. hit. norm du Rachis huniaino," I'hoso de Toulouse, 
iqoo. 




24 ANATOMY OF VERTEBEAL COLUMN AND THORAX 

PELVIC INCLINATION 

The position of the pelvis in relation to the horizontal plane 
would be of importance in relation to scoliosis and faulty attitude if 
it could be accurately measured in the living subject. 



GIRL 

1/2 YRS 

Sitting Front 



Standing 



.7"r"C 



LYIN'i 



-JTHC 



.4'f"L 



.4"^«L 



4THL. 




Fig. 17. — Tracings of Physiological Curves of Normal Children: on the Left of 
A Girl of One and a Half Years, on the' Right of a Girl of Eleven. 



If the front part of the pelvis is lowered and the back part cor- 
respondingly tilted up it is spoken of as ''increased inclination" of 
the pelvis. If the front part is raised and the back part lowered it is 
spoken of as "diminished inclination." With the former is asso- 
ciated an increase of the lumbar physiological curve, and with the 
latter a flattening of it. Changes in inclination of the pelvis must 
form an important element in the faulty attitude to be spoken of 
as round shoulders. 



PELVIC INCLINATION 25 

The internal or true conjugate diameter (conjugata vera) of the 
pelvis is a line from the sacrolumbar junction to the top of the sym- 
physis pubis and is generally accepted as the line by which pelvic 
inclination is to be determined. The angle which this line makes 
with the horizon when the patient stands erect is spoken of as the 
''angle of pelvic inclination/' and the observers do not wholly agree 
in their results. It is probable that no measurements of pelvic 
inclination in the hving subject are sufficiently accurate to be of value. 

In men the variation in the average of collected results is from 44 
degrees to 60 degrees, and in women from 41 degrees to 65 degrees. 
The results of Prochovnik were obtained by the most accurate 
method of any and the research was conducted entirely on living 
subjects. The variation in men, according to his figures, was from 26 
degrees to 76 degrees, and in women from 40.5 degrees to 71 degrees. 

A research by Reynolds and Lovett^ was undertaken as to the 
mechanics of the antero-posterior position in the upright living indi- 
vidual, in which research a determination of pelvic inclination and its 
variations under varying static conditions would have been of pre- 
sumable value, but after months of experimentation with various 
methods the investigators came to the conclusion that it was impos- 
sible to measure the variations in the inclination of the pelvis in a 
living individual with sufficient accuracy to be of any practical value. 

The following figures are therefore quoted in the behef that they 
can only be approximate and that they must be taken only in the 
most general way. They are partly obtained from the living, but in 
many instances are from the cadaver. 



Average in Average in 
Men Women 

Year 1745, Miiller 45 degrees 

Year 1825, Nagele^ 60 degrees 

Year 1836, Weber Brothers^ 65 degrees 

Year 1841, Krause^ 60 degrees 60 degrees 

Year 1873, Meyer^ 55 degrees 50 degrees 

Year 1882, Prochovnik'^ 54- 17 degrees 5172 degrees 

Year 1898, Henggeler^ 44 degrees 41 . i degrees 

^ E. Reynolds and R. W. Lovett: '' Journ. Am. Med. Assn.," j\Iar. 26, loio. 

2*'Das Weibl Becken," etc., Carlsruhe, 1825. 

^"Mech. d. Menschl. Gehwerkzeuge," Gottingen, 1836. 

^"Hdbch. d. Mensch. Anat. Hauft.," i, i, 324, Hanover, 1S41. 

5 "Miiller's Archiv," 1873, 9. 

6"Archivf. Gyn.," 1882, xix, i. 

■^ ''Zeitsch. f. orth. Chir.," xii, 4,613. 



26 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



In 1 910 Engelhard^ published some observations on pelvic inclina- 
tion in living children from six to fourteen. The extremes of inclina- 
tion were from 21 degrees to 46 degrees to the horizontal with an 
average inclination of 3 2 degrees. 

Seventy-six males and eighty females, all apparently normal, over 
the age of fifteen were investigated and tabulated by Prochovnik as 
follows : 

Least Inclination Greatest Average 

Males. 26 degrees 76 degrees 51.72 degrees 

Females 40.5 degrees 71 degrees 54-17 degrees 

The grouping of the results suggests that a normal pelvis shows an 
inclination of from 50 to 60 degrees, that there is a subnormal zone 

from 45 to 50 degrees, a supra- 
normal of 60 to 65 degrees, but 
that ' an inclination above 65 
degrees or below 45 degrees is to 
be regarded as pathological. The 
figures given refer to the external 
conjugate and are a little higher 
when the internal conjugate is 
taken as determining the angle of 
inclination. 

The whole subject of pelvic 
inclination and its variations, the 
influences of such changes of 
inclination on static conditions, 
and the difference of inclination 
between children and adults must 
therefore be left in an unsatisfactory and unsettled condition. 




Pig. 18. — Female Pelvis. Median 

Section. — {Spalteholz.) 
The solid line running up and back 
from the symphysis indicates the 
"external conjugate diameter." 



SURFACE ANATOMY OF THE BACK 

The position of the spine in the median line of the body is indicated 
on the normal back by a longitudinal furrow (median furrow) extend- 
ing from the occipital bone to the sacrum. The lower end of the 
furrow corresponds to the interval between the fifth lumbar vertebra 
and the sacrum. In the cervical region this furrow Hes between the 
trapezii and complexi, and in the dorsal and lumbar regions it Hes 
between the erector spinae muscles. It is usually most marked in the 
upper lumbar and lower dorsal regions. 

^ "Zeitsch. f. orth. Chir.," xxvii, page i, 1910. 



SURFACE ANATOMY OF THE BACK 27 

Identification of Vertebra. — In this median furrow the spinous proc- 
esses of the lower cervical vertebrae can be felt easily, but the spine 
of the second cervical vertebra can be reached by deep pressure in 
a relaxed neck; in a poorly developed individual they can be seen 
in the erect position, and in one well developed in forward bending. 
The spinous process of the seventh cervical vertebra is usually quite 
prominent, though that of the first thoracic may be still more so. In 
proceeding downward the root of the spine of the scapula should be 
found opposite the spinous process of the third dorsal vertebra, and 
the inferior angle of the scapula opposite that of the seventh dorsal 
vertebra. The spine of th^ fourth lumbar vertebra is on a level with 
the highest points of the iliac crests. The spinous process of the 
fifth lumbar vertebra is very short, and usually forms a slight de- 
pression instead of a prominence. The third sacral vertebra is on the 
line drawn between the posterior superior spines of the ilium, and this 
line Hes over the sacro-iHac joints. The twelfth dorsal vertebra is 
found by counting down from the seventh dorsal and up from the 
fourth lumbar vertebra, and any vertebra may be found in this way. 
Of the methods of identification this is the most reliable. In the 
dorsal region the obliquity of the spinous processes causes the tip of 
each to be opposite the body of the vertebra next below it. So the 
spine of the second dorsal vertebra corresponds to the head of the 
third rib, but the eleventh and twelfth dorsal spines are opposite 
the heads of the eleventh and twelfth ribs. The spinous processes 
of the lumbar vertebrae are opposite the lower parts of the corres- 
ponding bodies and the discs below them. 

In the adult the spinal cord ends at the lower border of the first 
lumbar vertebra; in children the cord terminates at the lower border 
of the third lumbar vertebra. 

Muscles. — The outHne of the neck posteriorly is formed by the 
trapezii and underlying muscles. The surface of the shoulder is 
shaped by the deltoid and the muscles underlying the trapezius. 
The posterior border of the axilla is formed by the latissimus dorsi, 
which also takes part in forming the contour of the lower part of the 
back. In action the anterior edge of the latissimus dorsi may be seen 
as a fold extending from the crest of the ilium to the axilla. The 
erector spinae muscles form a rounded prominence longitudinally on 
either side of the spine in the lumbar region. 

The following table from Gray's '^\natomy" gives the relation of 
the spines of the vertebrie to important organs: 



28 



ANATOMY OF VERTEBRAL COLUMN AND THORAX 



Tabular Plan of Parts Opposite the Spines op the Vertebrae (Gray) 



Cervical. 



Dorsal, 



Lumbar. 



1 7tli. 
3d. 

4th. 
8th. 
9th. 

loth. 

nth. 
1 2th. 

ist. 

2d. 

I 3d. 
[ 4th. 



Cricoid cartilage. Esophagus begins. 

Apex of lung: higher in the female than in the male. 

Aorta reaches spine. Apex of lower lobe of lung. Angle 
of bifurcation of trachea. 

Aortic arch ends. Upper level of heart. 

Lower level of heart. Central tendon of diaphragm. 

Esophagus and vena cava through diaphragm. Upper 
edge of spleen. 

Lower edge of lung. Liver comes to surface posteriorly. 
Cardiac orifice of stomach. 

Lower border of spleen. Renal capsule. 

Lowest part of pleura. Aorta through diaphragm. Py- 
lorus. 

Renal arteries. Pelvis of kidne3\ 

Termination of spinal cord. Pancreas. Duodenum just 
below. Receptaculum chyH. 

Umbilicus. Lower border of kidney. 

Division of aorta. Highest part of ilium. 



Points for Lateral Corrective Pressure. — The points at which cor- 
rective side pressure may be applied to the spine are determined by 
anatomical conditions. The important structures lying on both 
sides of the spine in the cervical and lumbar regions make it impos- 
sible to use effective side pressure upon a curved spine in these 
regions. In the dorsal region side pressure on the ribs is effective on 
the vertebrae, but it cannot be exerted on the upper vertebrae higher, 
of course, than the axilla. The anterior border of the axilla is formed 
by the' pectoralis major muscle and is in the line of the fifth rib. 
This rib articulates with both the fourth and fifth dorsal vertebrae. 
Although with the arm nearly at the side the third rib may be reached 
by the exploring hand, side pressure on the thorax cannot be exerted 
efficientlv above the fourth or fifth rib. 



CHAPTER III 
THE MOVEMENTS OF THE SPINE^ 

The movements of the human spine are three in number: (i) Flex- 
ion, (2) extension, and (3) a compound movement — side bending- 
rotation. 

• The statement that there are four movements (flexion, extension, 
rotation and side bending) is wholly incorrect, as neither side bending 
nor rotation exists in a pure form as may be demonstrated on any 
normar child. The statement that such movements exist as pure 
movements necessarily leads to a false basis for gymnastic exercises 
and obscures the whole mechanism of scoliosis. 

As long ago as 1844 Henry J. Bigelow wrote: ''The principle of 
torsion is illustrated by bending a flat blade of grass or a flat, flexible 
stick in the direction of its width. The center immediately rotates 
upon its longitudinal axis to bend flatwise in the direction of its thick- 
ness. In the same way the spine, laterally flexed, turns upon its 
vertical axis to yield in its shortest or antero-posterior diameter." 
Occasional references are found to the association of torsion with 
lateral flexion, but no general recognition of the relation between the 
two has existed. 

The human spine is not an extremely flexible structure taken by 
itself; much of its apparent flexibility is due to accessory movements 
between the spine and the head and the pelvis and the legs. An 
extreme forward flexion, e. g., in the iving model or the intact 
cadaver, with the flexed head, the drooping shoulders, and the 
rotated pelvis, implies a greater curve than the spine itself possesses. 
It is surprising to see in the cadaver how comparatively httle actual 
mobility is possessed by the three regions of the spine considered 
separately, or by the whole spine. 

The application of this is obvious without extended comment. 
If active or passive exercises are given which are intended to take 
effect upon the spine alone and to be effective there, the pelvis must 
be fixed. If this is not done, part of the muscular force is used in 
displacing the pelvis to the opposite side to balance the body, and 
the movement becomes a general and not a spinal one. 

^ R. W. Lovett: "Bos. Med. and Surg. Jour.," June 4, 1900, Oct. ^u, tooi. 
Mar. 17, 1904, Sept. 28, 1905; "Amer. Jour, of Anat./' ii, 4, 457. 



so 



THE MOVEMENTS OE THE SPINE 
I. FLEXION (FORWARD BENDING) 



Is a pure antero-posterior movement without perceptible rotation. It is the 
most evenly distributed of the spinal movements, and in extreme flexion the out- 
line of the tips of the spinous processes forms a curve approaching the arc of a 
circle. Most of the movement is accomplished in the lumbar region, which in 
extreme flexion loses most of its forward convexity, but in adult observations 
was not observed to become convex backward. 




Fig. 19. — Flexion of the Spine in the Model. 



The dorsal region in extreme flexion becomes decidedly more convex than in 
the upright position. The twelfth dorsal vertebra takes part in flexion more as a 
lumbar than as a dorsal vertebra, and free movement occurs below it and fairly 
free movement between the eleventh and twelfth vertebrae. 

The cervical region cannot be accurately observed or measured in the model. 
In the cadaver it dries, so rapidly that no conclusions can be drawn beyond the 
statement that its forward convexity may be obliterated by forcible flexion with 
the hands. 



FLEXION 



31 



The most marked flexion of the spine may be obtained by having the model 
sit cross-legged and bend forward with the chest between the knees. Extreme 
passive flexion with the model lying on the side is not so great as that obtained by 
flexion in the cross-legged position. 

In flexion the distance of the seventh cervical vertebra from the sacrum when 
measured along the spinous processes is increased over the same measurement 
taken in standing or lying. 




Fig. 20. — Hyperextension in the Model. 
The head is supported to secure steadiness. 



There seems to be no constant difference in the amount of flexion obtained in 
the standing and sitting positions, the resultant curve being practically tlie same. 
The chief difference between flexion in model and cadaver seems to consist in 
a greater relative participation of the dorsal region in flexion in the model. 

Measurements and tracings of the spine in the model and in children show 
the relaxed sitting positiofi to be one of slight flexion. 

Forward flexion of the spine in scoliosis lends to straii^/iten the curved line formed 
by the spinous processes. 



32 



THE MOVEMENTS OP THE SPINE 



II. HYPEREXTEXSIOX (BACKWARD BEXDIXG) 

Hj-perextension is a pure antero-posterior movement of the spine \N-ithout 
perceptible rotation. It is not an evenly distributed, movement, but occurs 
almost wholl}^ in the lumbar and lower two dorsal vertebrae. A tracing taken 
over the spinous processes in extreme h>'perextension in outline resembles a 
hockey stick. The dorsal region is but little affected, being slightly straightened 
by hyperextension. The bending reaches to about the tenth dorsal, the upper 
dorsal region showing but little diminution in the physiological curve, the twelfth 
dorsal vertebra, and, to a certain extent, the eleventh, behaving as do the lumbar 
vertebree in hj-perextension. The character of the curve obtained in marked 
h}*perextension is practicaU}- the same, whether it is obtained by active or passive 

means, and whether the model lies 
on the face or on the side, or stands, 
or sits. The column of vertebral 
bodies alone shows the same char- 
acter and distributioii of the move- 
ment as does the intact spine of the 
cadaver. The illustration (Fig. 21) 
shows the characteristic rigidity of 
the dorsal region to h}-perextension. 
In h}-perextension, the distance 
from the seventh cer\dcal vertebra 
to the sacrum, measured over the 
spinous processes, is decreased from 
the same measurement taken in the 
erect position. 

111(3. LATER-\L FLEXIOX (SIDE 
BEXDIXG) 

Lateral flexion of the spine does 
not exist as a pure movement, but 
is to be considered as one part of a 
compound movement, of which 
twisting or rotation forms the other 
part. 
In describing this side bending it must be stated that the character and distri- 
bution of the movement var}' widely according to the degree of flexion or exten- 
sion of the spine when the side bending is made. In other words, there is no 
one type of spinal side bending, as there are t\'pes of flexion and extension, but 
the character and distribution of the movements are wholly dependent upon 
whether the spine is flexed, erect, or h^-perextended when the side bending is 
performed. 

Side bending will first be considered alone without regard to the rotation caused 
b}^ it, and then the rotation accompanying each kind of side bending will be 
described. 

The extent and distribution of forward and backward bending have been 
investigated in children from six to fourteen years old b}'- EngeLhard,i and 
^ "Zeitsch. fiir orth. chir.," 1910, xxvn, p i. 




Fig. 21. — Hyperextension in the Cadaver. 



SIDE BENDING 



2>?> 



Fig. 31 shows the amount and distribution of these movements as formulated 
by him in an average individual. 

Side bending in lying on the face shows a more evenly distributed lateral 
curve than does that in the erect position. The character of the curve does not 
change essentially when the shoulders and pelvis are held and the middle of the 
trunk pushed to one side. The curve in this position of the spine is greater in the 




Fig. 22. — Side Bending to the Right in the Flexed Position of the Spine in the 

Model. 

A lateral curve convex to the left is formed and the vertebral bodies have turned to the left, 

as-shown by the elevation of the left ,side^of-the back. 



upper lumbar vertebrae and in the two lower dorsal than in the upper part of 
the spine. 

Rotation Accompanying Side Bending Lying on the Face. — With the cadaver 
lying flat on the face 'on the table no rotation in side bending was found by v. 
Meyer and in some experiments by Schluthess; it was, however, found by Benno 
Schmidt. With the cadaver lying prone on a table the conditions, of course, 
are against rotation, the thorax and shoulders being to a certain extent held 
against it by the surface of the table. No perceptible rotation is noted in slight 
3 



34 



THE MOA'EMEXTS OP THE SPIXE 



bending under these conditions, but the vertebral bodies turn to the concave side 
in marked side bending. In the model King flat on a table one side of the chest is 
felt to press on the table harder than the other in moderate side bending. The 
p)oint is not of great importance, as the practical problem is that of the beha\-ior 
of the weight-bearing spine. 

Side bending in the flexed position of the spine is a more evenl}- distributed 
movement in which the dorsal region participates more and the lumbar region 
less than in the erect position. The greatest de\-iation from a line coimecting the 
two ends of the spine occurs at about the eighth dorsal vertebra in both cadaver 




Fig. 23. — Side Bendixg in the Upright Position of the Model. 
The movement is chiefly located at the dorsolumbar junction. 



and model. In short, side bending occurs higher in the spine in flexion than in 
any other position, the lumbar region being comparatively locked against side 
bending by the flexed position. The more marked the flexed position, the 
higher in the spiae is the side bending localized. 

Rotation Accompanying Side Bending in Flexivv. — In the flexed position of the 
spinC; side bending is accompanied by rotation of the vertebral bodies toward 



SIDE BENDING 



35 



the convexity of the lateral curve. This rotation occurs chiefly in the dorsal 
region. 

Side bending in the Erect Position. — In the cadaver side bending is most 
marked below the tenth dorsal vertebra, and the dorsal region shares but slightly. 
The lumbar region is most affected in its upper part, but shares to some extent 
throughout. Side bending in the erect position is, therefore, largely a movement 
occurring in the neighborhood of and below the dorso-lumbar junction. It shows 
the same characteristics in the cadaver, the model, and the child, except that in 
the two last named the dorsal region takes a greater relative part than in the 
cadaver. 

Rotation Accompanying Side Bending in the Erect Position. — In this position 
side bending causes the rotation of the bodies of the vertebrae to the concave side 
of the lateral curve. This, however, occurs lower down in the spine than in the 
flexed position. The dorsal region participates less and the lumbar region more 
in the movement. 




Fig. 24. — Side Bending in the Upright Position of the Cadaver, showing the Same 
Characteristics as in the Model. 



Side Bending in the Hyperextended Position of the Spine. — With the spine 
of the cadaver, model, or child hyperextended, the side bending becomes a 
sharply limited movement, localized low down in the spine and occurring almost 
wholly below the eleventh dorsal vertebra, becoming therefore, essentially a lum- 
bar movement. The dorsal region bends as a whole upon the lumbar and rocks 
over to the side practically unchanged, being locked against side bending by the 
hyperextended position. 

Side bending, therefore, is situated highest in the fle.xed position, lower down 
in the erect position, and lowest in hypcrextension in the model, cadaver, and 
child. 



36 



THE MOVEMENTS OF THE SPINE 



Rotation Accompanying Side Bending in the Hyperextended Positiofi. — This is 
a sharply limited movement occurring in the lumbar region, including the 
twelfth dorsal as functionally a lumbar vertebra. The thorax rocks over to the 
side unchanged, and the rotation of the bodies is to the concave side of the lateral 
curve. 

Rotation accompanying side bending is, therefore, of a different type in the 
flexed position of the spine from what it is in the erect or h^'perextended position. 

III5. ROTATION 

Rotation or twisting of the spine is to be considered as part of a compound 
movement of which side bending forms the other part. For purposes of simplic- 
ity the rotation element of the movement will be considered b}^ itself. Under 




Pig. 25. — ^SiDE Bending to the Right in the Hypeeextended Position of the Spine 

IN the Model. 
The head is supported to secure steadiness. 



ordinary conditions it is essentially a movement of the dorsal and cervical regions 
in which the lumbar vertebrae take but Httle part except in hyperextension and 



ROTATION 



37 



with the use of traction. The lumbar vertebral region possesses some power of 
rotation, as has been generally observed. 

Rotation in the Erect Position. — Rotation is freest in the erect position and 
is situated in the cervical and dorsal regions, reaching its maximum at the top 
of the cervical column and extending down the spine to the lower dorsal region, 
where it disappears. With very forcible rotation applied to the top of the column 
in the cadaver, the first and even the second lumbar vertebra may be rotated. 
The rotation in this position is accompanied by a side bend of the rotated region 
away from the side to which the bodies of the vertebrae turn. If the rotation is 
to the right, it is accompanied by a lateral bend convex to the left and vice versa. 
In the model an active rotation to the right is accompanied by a displacement of 
the trunk to the left side and vice versa. If traction is applied to the head of the 
erect cadaver, forcible twisting of the head results in rotation of the lumbar 
vertebras, including the fourth. 





Fig. 26. — Side Bending to the Right in 
Hyperextension in the Column of Ver- 
tebral Bodies. 

The same characteristics are shown as in 
the previous figure. 



Fig. 27. — Side Bending to the Right in 
the Hyperextended Position of the Spine 
IN the Cadaver. The movement occurs 
chiefly at and below the dorsolumbar junc- 
tion, and the bodies of the vertebrae turn to 
the right, as shown by the pins. The lateral 
curve is convex to the left. 



Rotation in the Flexed Position.— Rotation in the flexed position of the 
spine occurs chiefly in the cervical and upper dorsal spine, the lower dorsal and 
lumbar region seeming locked against rotating forces by the flexed position. The 
more extreme the flexion the more markedly in cadaver, model, and child is the 
rotation restricted to the cervical and upper dorsal spine. 

Rotation in the Hyperextended Position. — In Inperoxtendcd positions rota- 
tion with moderate manual force occurs as a twisting of the whole thorax on 
an axis in the dorsolumbar region, the upper and niiddorsal regions apparently 



38 



THE MOVEMENTS OP THE SPINE 



being locked against rotation by hyperextension. The site of rotating movement 
in this position is, therefore, in the one or two vertebrae above and the one or two 
vertebrae below the dorsolumbar junction. 

Rotation, therefore, is located high in flexed positions, lower in erect positions, 
and is situated lowest and is more sharply localized, in h3q)erextended positions. 

Side Bends Accompanying Rotation. — A lateral deviation of the spine 
accompanies all rotations. It is situated at the site of the rotation and is convex 
to the right when the rotation is to the left and vice versa. In the erect position 
rotation causes a marked side curve in the dorsal region. 




Fig. 28. — Rotation of the Model, Face to the Right, Causing a Dorsal Lateral 
Curve Convex to the Left and a Displacement of the Trunk to the Left. 



Reasons for Torsion. — It is obvious from these experiments that there must 
be some fundamental reason for the constant occurrence of one type of torsion 
for side bendings in flexion and the occurrence of another type in extension, as 
well as for the constant association of torsion with side bending. The vertebral 
column is a flexible rod capable of bearing great weight. It is not equally flexible 
in all directions, but it is, of course, capable of some movement in all planes, and, 
as such, should come under the control of the laws governing flexible rods in 



TORSION 



39 



general. The extent of any of the movements of the spine is, of course, greatly 
influenced by the shape of the vertebral bodies, the curves of the spine, the 
character of the articular processes, the resistance of the ligaments, and the 
relative sterngth of the muscles. 

From the mechanical point of view, torsion results from any motion of a 
straight flexible rod in which all the particles do not move in parallel planes. 
Consequently, if such a rod is bent in two planes at the same time, torsion must 
inevitably occur. The vertebral column is not a straight flexible rod, but one 
bent in physiological curves in the antero-posterior plane ; side bending must 
therefore inevitably lead to torsion, because it means bending in two planes. 
Nor does the fact that the intervertebral discs permit motion in all directions 
affect the question, because from a mechanical point of view the vertebral column 
behaves in general as it would if it were a homogeneous, flexible rod. 




Fig. 29. — Rotation of the Spine of the 
Cadaver, Face to the Right, in the 
Flexed Position of the Spine. 

The movement is seen to be located in the 
upper part of the column by the deviation 



ip: 
of the pins« 



Fig. 30. — Rotation of the Spine of the 
Cadaver, Pace to the Right, in the 
Hyperextended Position. 
The movement is seen to occur in the lower 
part of the spine by the rotation of the pins. 



A strip of sponge rubber, half an inch in diameter and 14 inches long, rotates 
in the same way that the vertebral column does in the same position. A lateral 
curvature, in what corresponds to the flexed position of the spine, may be pro- 
duced in the rubber strip following the same rule of rotation seen in life; that is, 
the front of the rod turns toward the convexity of the lateral curve. An artificial 
lateral curvature in the rubber strip, made in what corresponds to the extended 
position of the spine, results in a reverse rotation to that from the rotation of the 
flexed position. A piece of rattan, a piece of rubber tubing, a strip of sponge 
rubber, round or square, the backbone of a fish, or the backbone of a cat. behave 
all in the same way, and rotate in the same direction as does the human spine. 



40 



THE MOVEMENTS OP THE SPINE 



\^ 



Articular Processes. — Although it is easy to understand that the column 
of vertebral bodies by itself might easily behave as a flexible rod, yet the articular 
processes cannot be left out of account. They must be an important factor in 
determining torsion, and they must do one of two things. Either they must fall 
in with the behavior of the flexible column of bodies and serve to carry out the 
rotation which would occur without them, or they must obstruct or reverse the 
rotation which would occur in the column of vertebral bodies alone. Experi- 
ments seem to show that the articular processes merely serve to accentuate the 

same rotation that would be present 
if the column of vertebral bodies 
^"^ were by itself. 

THE CERVIC.4L REGION 



Flexion. — It is possible to 
straighten the anterior physiological 
curve. Much of the apparent for- 
ward flexion in the cervical region in 
life is evidently due to the motion 
between the occiput and the atlas. 

Hyperextension. — The physiolog- 
ical curve can be increased to a certain 
extent. 

Side Bending. — Side bending is 
uniformly distributed throughout the 
cervical region and is accompanied 
by rotation of the bodies of the ver- 
tebra to the concavity of the lateral 
curve, as in the lumbar region. 

Rotation. — Rotation is extremely 
free between the first and second 
cervical vertebra, but for the rest of 
the region it is limited. Rotation is 
accompanied by a side bend convex 
to the side opposite to which the 
bodies of the vertebrae turn; that is, 
in a right rotation the curve is convex 
to the left. 




Fig. 31. — Diagram of the Spinal Move- 
ments IN a Living Child. — {Engelhard.) 
The solid, line shows the normal position, 
the dotted line the forward bend and the line 
of dots and dashes the hyperextended position. 



DORSAL REGION 

The dorsal region is the least mobile part of the spine as a whole. The twelfth 
dorsal vertebra from the point of view of function must be regarded as a lumbar 
vertebra and not as part of the dorsal region. 

Flexion. — The dorsal spine already convex backward can be made somewhat 
more convex by forward bending, but the extent of the movement is not great and 
by no means comparable to the same movement in the lumbar region, 

Hyperextension. — Hyperextension is a motion of very slight extent in the 
dorsal region. It consists of a diminution of the backward convexity and is most 
noticeable in the lower half of the region. 



CONCLUSIONS AS TO MOVEMENTS 4 1 

Side Bending. — Side bending of the dorsal region is a fairly evenly distributed 
movement of slight extent, presenting an even curve which is greatest in the mid- 
dorsal region. It is freest in the erect position or lying on the face. It occurs 
less markedly in flexed positions and least in hyperextension. Side bending in 
this region is always accompanied by rotation of the bodies of the vertebrae to 
the convex side of the lateral curve. 

Rotation is the most marked of dorsal movements. It reaches its greatest 
extent in the upper dorsal vertebrae and dirtiinishes toward the lower end of the 
region. In a rotation of moderate force in the upright position it extends to and 
includes the seventh or eighth dorsal vertebra. Rotation of the dorsal region is 
less easily accomplished in flexion than in the erect position and in hyperextension 
it is much hmited, while in extreme hyperextension in the cadaver the dorsal 
rotation movement seems to be obliterated. 

Rotation is accompanied always by side bending, the lateral curve being convex 
to the side away from which the bodies of the vertebrge turn. In a rotation of the 
top of the column to the left the lateral curve is to the right and vice versa. 

The practical points to be borne in mind in the study of the dorsal region are 
the facts that rotation is freer than side bending, that hyperextension is extremely 
limited, and that the region on the whole is comparatively immobile. 

LUMBAR REGION 

Flexion in the lumbar region is a movement of much freedom, but the physio- 
logical curve in the adult cadaver has not been obliterated in any case observed 
by the writer. 

Hyperextension as a general spinal movement is essentially a lumbar motion 
and in that region is an evenly distributed one. 

Side bending is a free movement in the lumbar region and forms in the erect 
position a very £venly distributed curve; it is greatest in the erect position and 
least in extreme flexion. 

The rotation accompanying side bending in the lumbar spine is always with the 
bodies turning to the concavity of the lateral curve, which is to be contrasted 
with the opposite rotation occurring in side bending in the dorsal region. 

Rotation in the lumbar region is extremely limited and is diminished by extreme 
hyperextension and is least of absent in extreme flexion. The lumbar region 
possesses marked mobility in flexion, hyperextension, and side bending, and but 
little in rotation. Side bending is more free than rotation in contradistinction 
to the relation of these two movements in the dorsal region. 



CERTAIN CONCLUSIONS AS TO THE MOVEMENTS OF THE THREE 
REGIONS OF THE SPINE 

1. In the lumbar region flexion diminishes mobility in the direction of side 
bending and rotation, and extreme flexion seems to lock the lumbar spine against 
these movements. 

2. In the dorsal region hyperextension diminishes mobility in the direction of 
side bending and rotation. Extreme hyperextension seems to lock the dorsal 
spine against these movements. 



42 THE MOVEMENTS OF THE SPINE 

3. In flexion of the whole spine side bending is accompanied by rotation of 
the vertebral bodies to the convexity of the lateral curve, the characteristic of the 
dorsal region. 

4. In the erect position and in hyperextension of the whole spine side bending 
is accompanied by rotation of the vertebral bodies to the concavity of the lateral 
curve, the characteristic of the lumbar region. 

5. The dorsal region rotates more easily than it bends to the side, whereas 
the lumbar region bends to the side more easily than it rotates. 

6. Rotation in the dorsal region is accompanied by a lateral curve, the con- 
vexity of which is opposite to the side to which the bodies of the vertebrae rotate. 

These conclusions are true of the normal spine, but they do not necessarily 
apply to a deformed scoliotic spine. The nearer a scoliotic spine approaches the 
normal, the more likely are they to apply without modification. 



CHAPTER IV 
MECHANISM OF SCOLIOSIS 

The Mechanics of the Upright Position (Balance).— The spine 
is a curved, segmented, weight-bearing rod resting in unstable 
equihbrium on the sacrum, which forms part of a bony ring bal- 
anced on the hip-joints. Its upright position is due to a sense of 
balance possessed by the living individual, for if the cadaver is placed 
in the upright position it falls on account of the absence of muscular 
action. This sense of balance expresses itself in the complex action 
of many muscles by which the living individual keeps his center of 
gravity over the center of support. It is reflex and instinctive, and 
the individual has no knowledge of it as such, any more than he has 
of the mechanism of breathing or swallowing. 

The living individual, therefore, keeps his spine erect, first, because 
he has a sense of balance, and second, because he has a muscular 
system which responds to his instinctive nervous impulses and 
carries out of itself the necessary muscular adjustment which is too 
complicated to formulate in any detail. This instinctive sense of 
balance and equilibrium must be regarded as an attribute of the 
erect living individual, and must be given a place in the study 
of scoliosis. It is effective in two directions : 

1. The erect person instinctively strives to keep the head approxi- 
mately over the middle of the pelvis, that is, in the sagittal or antero- 
posterior median plane of the body. 

2. The erect person instinctively strives to keep the face to the 
front and the shoulder-girdle approximately in the same plane as 
the pelvis, i.e., in the frontal or lateral plane of the body. 

This adjustment, especially the element which seeks to keep the 
shoulder-girdle in the same plane as the pelvis while disturbances 
twisting the column below are taking place, is an important factor 
in explaining the phenomena of scoliosis, as will be seen later. 

The body is, however, not a firm mass, but consists of segments 
joined together, one segment resting upon the other, and firmly 
connected by a tube made up of muscles, fasciae, and integument.^ 

^ Feiss: '' Amer. Jour. Orth. Surg.," iv, r, 7,^. 

43 



44 



MECHANISM Or SCOLIOSIS 



n 



Since to maintain the erect attitude the Hne of gravity must pass 
through the base of support, so in all positions in which balance is 
maintained there is a constant equilibration by means of shifting 
segments. 

It is necessary at this place to introduce certain elementary points 
in mechanics which are familiar to every one. 

These points are the following: 

I. The base of support of the upright human figure consists of a 
trapezoid formed by the outer borders of the feet and lines connecting 

the back of the heels and the 
front of the toes. 

2. The center of support lies 
y^Hfe ,, perpendicularly under the cen- 
^^P ^^ ^^^ ^^ gravity and in the erect 

^ ^£i^. position must always lie within 

this trapezoid. 

3. For the purpose of study- 
ing the mechanism by which 
any weight is borne by a solid 
body in unstable equilibrium, 
the entire weight may be re- 
garded as concentrated in the 
center of gravity, and the 
determination of the relation 
between the center of gravity 
and the bearing points deter- 
mines the lines of stress. 

The Defects of the Upright 
Position. — An important mat- 
ter in the mechanics of the 
spine and its appendages is 
that it is evolved with comparatively slight modifications from 
the quadruped spine, and, in fact, is hardly more than quadruped 
spine set upright. In the quadruped the spine is a horizontal 
sustaining structure arched upward, supported at one end by two 
anterior limbs and at the other by two posterior limbs 5 the viscera 
hang directly down from this, being supported by ligaments and 
attachments at right angles to the supporting structure. On 
account of the angle of the ribs the thoracic cavity is helped in 
inspiration by gravity as the ribs fall into the position of thoracic 
expansion, but they must be pulled up to contract the thorax; and, 




Fig. 32. — The Right Side of the Pelvis 
OF the Cadaver is Raised and the Upper 
Part of the Spine Falls to the Left, 
Making a Lateral Curve Convex to the 
Right. 



MECHANISM OF' SCOLIOSIS 



45 



finally, equilibrium is much more easily maintained than in the 
biped, because the supporting base is broad and the weight of the 
mass to be supported is comparatively small. 

When this structure with only comparatively slight modifications 
is set on end and made to fulfil the functions of a weight-bearing 
column in a plane at right angles to that for which it is best adapted, 
certain unfavorable factors are introduced which serve as distinct 




Fig. 33. — The Right Side of the Pelvis of the Model is Raised and the Upper 
Part of the Spine is Carried to the Right, Making a Lateral Curve Com^EX to the 
Left. (Cf. Fig. 44.) 

limitations. The column constructed to bear weight and sustain 
strain at right angles to its long axis must now bear weight and sus- 
tain strain in its long axis. The two anterior hmbs, which formerly 
served as props, now hang as dead weights to be supported by the 
column. To maintain equihbrium much greater muscular effort 
is necessary to maintain functional balance in the man than in the 



46 MECHANISM OF SCOLIOSIS 

quadruped. The viscera hang no longer at right angles to the sup- 
porting structure, but in the line of its long axis. The thorax to 
expand has to raise all the ribs and work against gravity. 

But what is most important in the present connection is the fact 
that the upright position is decidedly hard to maintain, because the 
base of support is so small and the height of structure to be supported 
is relativeh' so great. 

This structure from a mechanical point of view consists of twcr 
vertical legs attached to a horizontal pehds in the middle of which is 
set an upright column expanding into a bony cage carrjdng the 
weight of arms, head, and thoracic contents. All the weight comes 
doTsm through a single column, the lumbar region of the spine, which 
column rests upon the middle of the pelvis. Such a structure is 
one necessarily susceptible to disturbances of balance, and it will 
yield to such disturbances by assuming abnormal curves either 
lateral or antero-posterior. 

Relatiayi of Balance to Curves. — If the peMs of a cadaver is raised 
on the right side and the upright spine is left free to move, the top 
of the column falls to the left and the spine is curved convex to the 
right. This is the position induced by gra\-ity. If, on the other 
hand, the right side of the pelvis of a Hving model is raised and the 
upright spine is left free to move, the top of the column remains 
upright and the spine is curved in the opposite direction, convex to 
the left. This is the position of balance overcoming the position 
induced by gra\-ity necessary to keep the centre of gra\'ity over the 
centre of support. The sense of equihbrium has worked against 
the force of gra\dty and has reversed the position natural to the 
cadaver. 

Anything which causes any part of the body to be held in an 
asymmetrical position will cause a lateral de\dation of some part 
of the spine, because a straight erect spine in the sagittal plane is 
possible only when the person stands on both feet or sits erect 
with the arms in similar positions and the head pointing straight 
ahead. Every step, ever}- raising of the arm, ever}- tilting of the 
head is accompanied by a deviation of the spine from the median 
plane of the body: in other words, by a temporary lateral curve 
which disappears as the symmetrical attitude is resumed. 

If there is a visual error that causes the head to be held obhquely; 
if there is a short leg causing the pelvis to be no longer horizontal but 
slanted; if the muscles of one side of the back are paralyzed; there 
must be a constant compensation or curve which will still enable the 



PLASTICITY OF BONE 



47 



center of gravity to be held over the center of support. When such 
a curved position becomes habitual for any of the reasons given or 
for other reasons, there exists in the adaptive character of bone a 
reason why this constantly assumed malposition should make a 
change in the shape of the bones in a growing child and that these 
changes should become fixed. 

Plasticity of Bone. — The adaptabiUty of 
bone to pressure has been recognized in gen- 
eral, and has been formulated and forms one 
aspect of what is often spoken of as Wolfif's^ 
law, which may be expressed briefly as 
follows: ''Every change in the formation 
and function of the bones, or of their 
function alone, is followed by certain definite 
changes in their internal architecture and 
equally definite secondary alterations of their 
external conformation in accordance with 
mathematical laws." 

The phenomena of lateral curvature have 
become somewhat more comprehensible since 
we have understood that bone is a plastic and 
adaptable structure, adapting itself to the 
demands on it, following in its growth the 




Fig. 34. — Experimental 
Scoliosis in a Rabbit 
Produced by Cutting 
THE Erector Spin^ 
Muscles. — (Arndt,) 



Fig. 35. — Fifth Lumbar Vertebra 
FROM Experimental Scoliosis in 
Rabbit. — (Arndt.) 



lines of least resistance, and in children susceptible to great changes 
in shape from abnormal conditions. As an instance of this may be 
mentioned the great distortion of the shape of the bones in the 
Chinese lady's foot produced by bandaging. It is not necessary to 

1 Wolff: "Das Gesetz der Transformation der Knochen," Berlin, 1S92; 
Freiberg: "Am. Jour. Med. Sci.," Dec, 1902; "Animal IMechanics," by Sir 
Charles Bell and J. Wyman, Cambridge, 1902. 



48 MECHANISM OF SCOLIOSIS 

multiply them, for we have direct experimental proof of the case 
in question in the experiments of Wullstein and Arndt. 

Wullstein^ showed, by bandaging young dogs for months in posi- 
tions with the spine bent laterally in some and in others bent con- 
vexly backward, that a permanent bony deformity occurred which 
could not be removed by traction in the length' of the spine after 
death. A section of these columns showed wedge-shaped deformity 
of the vertebrae with a ''lipping" or overgrowth of the borders of the 
vertebrae on the concave side of the curve, the trabeculae being 
thickened on the side of the bodies toward the concavity. The 
changes were more marked at the articular ends of the bones than in 
the middle of them. 

Arndt^ produced similar permanent curves, characterized by bony 
deformity and marked rotation, in rabbits by extirpation of the erec- 
tor trunci muscles on one side. They showed, as in Wullstein's ex- 
periments, that the changes are greatest at the articular ends of the 
bodies, and the epiphyseal plates in the most deformed vertebrae 
clearly overlap the sides of the body. 

The point to be remembered is, that the erect position is a singu- 
larly unstable one and temporary lateral deviation of the spine occurs 
in almost every movement of the body. If such deviation becomes 
permanent for any reason, it must further be remembered that grow- 
ing bone is a plastic structure and that the spine will tend to conform 
its bony shape to the abnormal position. Here then, exists the 
mechanism for the acquiring of bony lateral curvature if sufficiently 
long continued. There are, of course, many other causes of lateral 
curvature which will be mentioned. 

TYPES OF LATER.^ CURVATURE 

There are two types of malposition commonly described as lateral 
curvature or scoliosis. This is unfortunate and leads to misunder- 
standing and confusion. In one, the position is that which any 
normal spine may assume; in the second, the position is one that the 
normal spine cannot assume, a position which implies a change in 
the shape of the bones. 

It would add much to a better understanding of the subject if the 
first were called faulty attitude, false scoliosis, or some similar name, 
and the term scoliosis were reserved for the second form. 

1 "Zeitsch. f. orth. Chir.," x, 2. 

2 "Archiv f. orth. Chir.," i, i, 2. 



BONY ROTATION 



49 



The first is due to the adjustment necessary to keep the balance of 
the spine in the presence of one of the disturbing causes mentioned. 
If this becomes habitual, it results 
in a typical attitude to be described 
as total or postural lateral curvature in 
the chapter on Description and 
Symptoms. This attitude may 
persist as such or change to the 
second form to be described next. 

The second type of lateral curva- 
ture is accompanied by a change in 
the shape of the bones and soft 
parts. It cannot be repioduced 
experimentally in the model, cadaver, 
or child, and is not within the 
physiological limits of the spine. It 
must, therefore, be classed as true 
structural or organic lateral curvature. 
The characteristic feature is a local 
backward prominence of the ribs or 
lumbar transverse processes in the 
curved region, which is called "bony 
rotation." 

Bony Rotation. — The reason that 
bony rotation or twisting of the 
vertebral bodies always accompanies 
organic lateral curvature, has been 
widely discussed. The facts seem 
to be these : the vertebral column is a 
flexible weight-bearing rod curved in 
the antero-posterior plane by the 
physiological curves: if now lateral 
curvature begins, it is also curved to 
the side as well as in the antero- 
posterior plane. Growing bone is a 
plastic structure and its plastic 
weight-bearing column already 
curved in one plane cannot yield in 

another plane {i.e., to the side) without twisting, and in this twist 
the vertebral bodies can turn in only one way, namely, away from 
the greatest weight and pressure, which is, of course, on the con- 

4 




Fig. 36. — Experimental Scoli- 
osis IN A Young Dog Produced 
BY Bandaging in a One-sided 
Position. — {WuUsetin.) 



50 MECHAXISM OF SCOLIOSIS 

cave side of the lateral curve and the bodies turn away from this 
to the convex side of the lateral curve. If they were to turn 
toward the middle line instead of away from it they would encounter 
the greater instead of the less resistance and have to raise the whole 
weight of the parts above them. In so far as they are plastic they 
will be compressed where the weight is greatest or on the concave 
side. The deformity of the vertebrae is therefore due to their turn- 
ing where they must turn to escape, and to their plasticity \delding 
to conditions of unequal strain. 

Double Curves. — The explanation of a double curve is more 
difficult. It has been observed that frequently a double organic 
cur\^e grows out of a single functional one, the reason for which will 
be explained in the chapter on Description and Symptoms. It 
cannot be said that every case of organic double curve has first 
been a single postural one, but the mechanism is present for forming 
double curves from single ones under the influence of existing condi- 
tions. The occurrence of bony change in some cases and the persis- 
tence of functional curves in others can only be explained by assuming 
a plasticity of the bones in certain individuals which does not exist 
in the bones of others. 

The chain of events in the cases where a single curve changes to 
a double one is then, first, a disturbance of the symmetry of the body 
and the appearance of a functional curve; second, the persistence of 
this curve from the same causes that started it, the phenomena being 
still within the normal mechanism of the spine; third, the pelding of 
plastic vertebrae in the hne of least resistance and the appearance of 
rotation on the convex side of the lateral curve; fourth, the formation 
of double curves from single ones by the normal mechanism of the 
spine originating in the sense of balance and adjustment. It seems 
that in many cases, perhaps the majority, these steps cannot be 
traced, but coincide in time. 



CHAPTER V 

DESCRIPTION AND SYMPTOMS 

SYNONYMS 

English: Scoliosis, lateral curvature of the spine, rotary lateral 
curvature of the spine. 

German: Skoliose, seitliche Riickgratsverkriimmung, Kypho- 
skoliose. 

French: ScoHose, deviation laterale de la taille. 

Italian: Scoliose. 

Scoliosis, or lateral curvature of the spine, is the name applied to a 
condition in which any series of vertebral spinous processes show a 
constant deviation from the median line of the body, a deviation 
always accompanied by an element of twisting. In certain rare cases 
the twisting may be the predominant appearance. Deviation of a 
single vertebra from the median line does not constitute scoliosis. 

Although. scoliosis is generally studied and classified as a deformity 
of the spine, the laws of equilibrium of the body are such that any 
deviation of the vertebral column must disturb the whole balance of 
the body, and scoliosis is, therefore, accompanied by compensating 
lateral displacement of the pelvis and legs. In this wider sense 
scoliosis is to be regarded as a deformity of the whole body, espe- 
cially manifest in the spine. 

Lateral curvature of the spine is necessarily accompanied by a 
distortion of the symmetry of the body for which the patient or her 
parents seek advice. It is not generally recognized by the laity as a 
spinal distortion, but the patient is brought for surgical advice 
because of "a high shoulder," "a prominent hip," or ''a projecting 
shoulder-blade." Very often the dressmaker is the first to recognize 
it because she finds that she must make the skirt longer on one 
side than on the other, or because the distance from the armhole to 
the waistband is longer on one side than on the other. 

The condition is essentially a distortion, and symptoms other than 
the deformity are rather unusual in average cases. Occasionally the 
patient complains of feeling '' one-sided," but this is rare. Pain is 
generally not complained of, but in neurasthenic young women, 

51 



52 DESCRIPTION AND SYMPTOMS 

especially with functional curves, backache may be felt more or less 
on standing. Pain in the severer cases is caused by the descent of the 
ribs to the level of the crest of the ilium against which the lower ribs 
may rub, and severe local pain may be felt. In other severe cases, 
nerve-root pressure may result from the distortion and be referred to 
the peripheral ends of the spinal nerves ; this generally occurs during 
or after middle life. 

The shortening of the trunk and the diminished capacity and im- 
mobihty of the thorax may lead to impairment of the function of 
thoracic and abdominal organs, especially in severe cases, and short- 
ness of breath is common in such cases on account of diminished 
respiratory capacity. Displacement of the heart and phthisis fre- 
quently occur in severe cases during adult life. Disturbances of 
digestion are also frequent from displacement of the stomach and 
liver. Impairment of vigor and of the general health generally 
result in severe cases in adult life, although children with severe 
curves, as a rule, suffer less deterioration of the general condition. 

It is not uncommon for patients to go through Ufe with curves of 
moderate degree which have given rise to little or no trouble; but 
at or after middle hfe, when atrophy of the intervertebral discs has 
occurred, such curves may increase and give rise to a sense of asym- 
metry or to pain in the back or at nerve terminations. It can gen- 
erally be predicted that a curve of moderate severity may be more 
troublesome in later adult life. 

TERMINOLOGY 

The terms used in describing lateral curvature must be defined. 
Curves are named right or left according to their convexities, curves 
convex to the right being called right curves, and vice versa. In 
addition to the terms right or left, the curves are named also accord- 
ing to the anatomical region involved in the curves. If a deviation 
involves the whole spine, it is caUed a total curve; all other curves 
are called cervical, dorsal, or lumbar, according to the region in- 
volved, with the qualifying adjective right or left preceding the 
anatomical name. If a curve involves more than one region, it is 
classed as cervicodorsal or dorsolumbar. If two curves exist, the 
upper curve is spoken of first and the lower follows, e.g., right cervico- 
dorsal, left dorsolumbar; or right dorsal, left lumbar. 

It is important that the anatomical region affected by the curve 
be designated accurately and not loosely. For this purpose the 



i 



FUNCTIONAL SCOLIOSIS 53 

seventh cervical and last lumbar vertebral spines are marked on the 
skin and connected by a string representing the long axis of the spine. 
Parts of the spine lying to the right of this line are to be classified as 
right curves, parts to the left as left curves. Such curves must be 
assumed to begin and end where they pass under this string. For 
example, if the spine from the seventh cervical to the twelfth dorsal 
is to the right of the line and below it is to the left, it is a right-dorsal, 
left-lumbar curve. If the spine from the fourth dorsal to the third 
lumbar is to the right of the line, it is a right dorsolumbar curve. 

This, therefore, provides for a simple rule for the naming of every 
curve, insisting on the fact that the location of the upper end of the 
column has nothing to do with the naming of the curve. The upper 
end of the spine may be in the median plane or at either side of it, 
without affecting in any way the recognition and description of the 
-spinal curves. 

The classification of curves into primary and secondary, or com- 
pensatory, IS not of great importance, nor is it sound, as one cannot 
always say which curve was really primary. Generally it is obvious 
that one curve is predominant and evidently the one to be attacked 
in treatment. In some cases however, the curves are of equal degree 
and importance so far as can be seen. It is, however, of importance 
to recognize the predominant curve when possible. For example, 
in a marked and predominant right dorsal curve it matters but little, 
practically, whether a slight lumbar curve exists or not; for purposes 
of treatment the case is a dorsal curve. In general, rational treatment 
must eliminate unimportant factors and deal with the salient ones. 

The former division of lateral curvature into stages has no rational 
basis. It is a progressive affection passing over only one sharp line, 
the transition from postural or functional curves to structural or 
organic ones. This classification of functional and structural will, 
therefore, be adopted here with slight emphasis on a certain puzzling 
type of case evidently in . the transitional stage from the functional 
to the structural type. 

FUNCTIONAL SCOLIOSIS (TOTAL, POSTURAL, OR F.ALSE 

SCOLIOSIS) 

The term ''functional scoliosis" is applied to cases where the 
spine forms one gradual curve to one side without compensatory 
curves. In go per cent, of such cases the curve is to the left. Accord- 
ing to the figures of Scholder and at the Children's Hospital clinic. 



54 



DESCRIPTION AND SYMPTOMS 



right total scoliosis is very rarely seen, while the left curve is very 
common. The greatest point of deviation, i.e., the apex of the curve, 
is generally found at the ninth or tenth dorsal vertebra, but it may be 
found in any part of the lower half of the dorsal or upper half of the 
lumbar region. 

In frequency of occurrence total scoliosis stands in the fourth 
place in the records of the institute of Liining and Schulthess, where 

patients came for treatment, form- 
ing but 15.39 per cent, of the entire 
number of lateral curvatures. As 
to sex, the percentage shown in 
these cases is 24 for males and 17 
for females (Figs. 37 and 38). In 





Fig. 37. — Left Total Curve. 



Fig. 38. — Left Total Curve Bent Forward, 
Showing Prominence of Back on the Right. 



boys the number of total scolioses increases steadily with age, but 
in girls a decrease is noted after the twelfth year, coinciding with an 
increase in the number of left lumbar curves. Total scoliosis is 
found between the ages of five and eighteen years, as a rule. 

The deviation at the greatest curve is not often over an inch and a 
half from the median line of the body. There is no obvious compen- 
satory curve, and the untrained eye is Hkely to find slight cases 
normal. There is, however, a perceptible displacement of the trunk 
to the left, especially as seen from the front, and a plumb-line sus- 
pended in the median line of the body as defined by the vertical fold 



FUNCTIONAL SCOLIOSIS 55 

between the buttocks, will detect a decided deviation of the marked 
spines from the median plane. The typical characteristics of a left 
total scoliosis are as follows: (i) ^ general curve convex to the left; 
(2) the left shoulder is elevated; (3) the right side of the shoulder- girdle 
is carried hack and the left side forward;. (4) when the patient bends 
forward the right side of the back may be slightly higher than the left. 
Any case which simulates a left total curve and in which these signs 
are not all present should be subjected to the closest examination and 
will probably be found to be transitional in character. Functional 
curves disappear on suspension or recumbency, and side flexibility 
is but little Hmited, bending to the left being often somewhat re- 
stricted. In cases of right curves the description is reversed. 




Fig. 39. — Left Total Curve. The Patient from which Radiogram was Taken. 

The twisted relation of the shoulders to the pelvis is more evi- 
dent in children with marked lumbar physiological curves than in 
cases with round backs. ^ 

The position in a typical functional total curve is merely the 
physiological one necessitated in every normal spine for any reason 
made convex to the left, and can be produced experimentally by put- 
ting a book under the right foot, which raises the right side of the 
pelvis and necessitates for balance a left convex curve of the spine. 
A spine making any bend convex to the left in the erect position will 
turn at its upper end to the right, as explained in the movements of 

^Schulthess: "Zeitsch. f. orth. Chir.," vi, 3Qg-566, 1Q02. 



56 



DESCRIPTION AND SYMPTOMS 



the spine. The thorax and shoulders will be twisted backward on 
the right, and when the patient bends forward, this twisted position 





V^^w;j^j>- 



--'ff^^frf'jfc'^t.'^igf^-, 



Fig. 40. — Radiogram of Total Curve in Patient Shown in Fig. 39- 

of the shoulders may be carried over into the position of forward 
bending, if the case has been of long standing, and the right side of 
the back will be higher in this position. This "reverse rotation," 



TRANSITIONAL CURVES 



57 



"concave torsion," "retrotorsion," as it has been called, has been 
much discussed^ and is an accompaniment of total scoliosis, but it is 
a physiological matter easily understood by studying the mechanics 
of the normal spine. It has been claimed that total scoliosis is 
really a triple-compound curve, ^ and that the torsion to the concave 

side is really due to a slight 
right dorsal curve; x-rays of 
such cases taken in the stand- 
ing position show, however, 
in many cases, a gradual 
curve to the left without 
compensating curves (Fig. 
40) ; in other cases apparently 
total curves in A;-rays taken 
in this, way seem to be 
transitional cases. 





Fig. 41. — Case of "Paradoxical Dor- 
soLUMBAR Scoliosis" Figured by Wilbou- 
CHEWiTCH. (Compare Figs. 37-39.) 



Fig. 42. — Same Case as in Fig. 41 
Bent Forward Showing Prominence 
of Ribs on Right Side with Left 
Curve. — {Wilhouchewitch.) 



TRANSITIONAL CURVES 

In many cases which on first inspection appear to be postural more 
careful examination will show that the curve is. obviously changing 
from the postural to the structural type, i.e., is beginning to show 
changes in structure. 

In such transitional cases the upper part of the spine is less curved 
than the lower, and one or more of the characteristic signs of postural 
curves are most often wanting. For example, the right shoulder may 
be elevated in a left curve, or the left side of the back may be promi- 



1 Schulthess: "Zeitsch. f. orth. Chir.," x, page 489. 

2 Reiner and Werndorff: "Verhandl. Deut. Gesel. f. orth. Chir.," 1906, page 
232. 



58 DESCRIPTION AND SYMPTOMS 

nent upward in forward bending, or the left shoulder may be carried 
forward. Such cases must, of course, be recognized as early struc- 
tural cases, but are so nearly postural that they may be wrongly 
classed unless identified. It is not exceptional that in a curve that 
has been clearly a t>^ical left postural one, to notice a few m^onths 
later the dorsal spine is straightening and even becoming shghtly 
curved to the right, while the twist of the shoulder-girdle disap- 
pears or become reversed. 

The mechanism of this is as follows: 




Fig. 43. — Boy with Left Scoliosis Photographed from Overhead, Showing the 

Carrying Back of the Shoulder-girdle on the Right. 

The front edge of the board on the floor marks the lateral plane of the pelvis. 

Mechanism of Transitional Curves. — If total scoliosis tends to increase, it must 
do so by an increase of the existing side bend and of the existing twist, since 
both factors are correlated. The shoulder-girdle will, therefore, be more 
twisted as the lateral curve increases. One, however, does not see the condition 
chnicaHy of extreme left total curve and extreme right backward rotation of the 
shoulder-girdle except, possibly, in cicatricial, hysterical, or paralytic cases. An 
adjustment apparently takes place when the tendency of the total curve to 
increase passes beyond a certain point. For the explanation of this, one naturally 
looks to the instinctive tendency to equilibrium and balance spoken of as an 
intrinsic property of the upright living spine. There must be going on at all times 
this effort to square the shoulder-girdle with the pelvis and to keep the head and 
upper spine as nearly as possible in the median line of the body. This adjust- 
ment will naturally occur where the spine offers the least resistance to it, and as 



TRANSITIONAL CURVES 



59 



individual vertebral columns vary, the compensatory adjustment will take 
various forms. 

Assume that a child stands and sits with a left total curve. He will, after a 
certain point in the deformity is reached, be continually striving instinctively and 
unconsciously to twist the upper part of his spine and his shoulder-girdle forward 
on the right and to bend the upper part of his spine convex to the right to restore 
his balance. We have seen that the dorsal spine twists more easily than it 
bends to the side. He is, therefore more likely to twist his dorsal spine than 
to bend it to the side. He will, for this reason, twist the upper dorsal spine to 
the left, which twist, as we have seen, necessarily carries with it a dorsal lateral 
curve convex to the right. 




Fig. 44. — The Upper End of the Spine 
OF THE Cadaver is Held by the Hand over 
THE Middle of the Pelvis, while the 
Right Side of the Pelvis is Raised, and 
A Position Like that of the Living Model 
IS Produced with a Lateral Curve Convex 
to the Left. (Cf. Fig. 33.) 



Fig. 45. — Experimental Double Curve 
(Right Dorsal, Left Lumbar) Produced 
IN the Cadaver by Elevating the Right 
Side of the Pelvis and Twisting The 
Upper End of the Spine, Face to the 
Left. 



The tendency to correct the twist of the shoulder and upper end of the spine 
is sufficient to explain the transition of a left total curve to a right dorsal, left 
lumbar curve. Such a double curve can be reproduced experimentally in the 
cadaver, the model, and the child by inducing a left total curve and adding a 
twist, active or passive, of the shoulder-girdle forward on the right. A right 
dorsal, left lumbar lateral curve then exists. 

Support is given to this idea by the fact that in structural right dorsal, left 
lumbar curves with bony rotation, one is likely to find in looking down upon the 
standing patient that the left side of the shoulder-girdle is seen to be carried 
backward in its relation to the pelvis and the right side forward, which, of course, 
is the reversed position to that seen in the left total curve. The same relation 



6o 



DESCRIPTION AND SYMPTOMS 



of the shoulder-girdle is to be noticed in single curves to the left which are ac- 
companied by bony rotation, the position again being the reverse of that seen in 
left total scoliosis. 

The disappearance of concave-sided torsion which has once existed in any 
part of the spine may indicate that the compensator^^ change has already begun 
and that the so-called total scoliosis has begun on its transition to a compound 
curve. 

We should, therefore, regard with suspicion any case of apparent total-^coliosis 
that shows any departure from the chnical tj-pe described (see page 55), such 
cases probably ha\-ing entered on the stage of transition. 




Fig. 46. — ExPERLMENT.vL Double Curve (Right Dorsal, Left Lu-MB.AJi) Produced 
IN THE Model by Elevatixg the Right Side of the Pelvis and Having the Model 
AcTiN^LY Twist the Upper Spine, Face to the Left. 



That left total curves most frequently change to right dorsal, left 

lumbar compound curves than to any other form is sho^m by the 

figures of Hess and by a statement of Schulthess.^ But we cannot 

expect the same final curve always to result from the same initial 

iLiining and Schulthess: "Orth. Chir.," 1901, page 248. 



STRUCTURAL SCOLIOSIS 6l 

curve. Various forms of curves may occur from the same simple 
curve. For example, the dorsal region may not react as described, 
and the dorsal and lumbar region may yield, as a whole, to the left, 
later showing bony rotation on the left side. The spine has yielded 
backward and to the left as a whole, and other types of compound 
curves may obviously result from the same initial curve. 

In his investigations concerning the persistence of total scoliosis 
Hess records the observations of 86 cases between the ages of five 
and twenty-one years during periods varying from two weeks to 
eight years and a half. Of these 86 cases, 60 persisted as total sco- 
lioses, and the remaining 26 underwent various changes, as shown by 
the list given below. 

(a) Left total scoliosis in — 

7 cases changed to right dorsal, left dorsolumbar scoliosis. 

4 cases changed to left lumbar curves, with two right dorsal 

3 cases changed to left dorsal curves. 

2 cases changed to left dorsal, right dorsolumbar curves. 

2 cases changed to right dorsal curves. 

I case changed to left dorsal, right dorsolumbar. 

I case changed to slight left cervicodorsal curve. 

I case showed slight compensating curves. 



(b) Right total scoliosis in — 

I case became right dorsal, left dorsolumbar. 

I case became left dorsal, right dorsolumbar. 

I case became left dorsal. 

I case became right dorsal. 

I case became left dorsal, right lumbar. 



5 cases. 



STRUCTURAL SCOLIOSIS (ORGANIC, HABITUAL OR 
TRUE SCOLIOSIS) 

This term is applied to those cases in which there is reason to 
believe that a structural change has occurred in the vertebrae, which 
is discussed in the chapter on Pathology. 

Structural curves are simple or compound — simple, when the de- 
viation is accompanied by no compensating curves, e.g., left lumbar 
scoliosis. The scoliosis is compound when more than one curve is 
present, e.g., right dorsal, left lumbar scoliosis. The simple curves 
have sometimes been spoken of as C curves and the double as S 



62 



DESCRIPTION AND SYMPTOMS 



curves. Triple curves at tirues exist. When compound curves 
are present, they alternate to the right and left, two left curves, e.g., 
not separated by a right curve, never being seen. 

No attempt has been made 
to discriminate between the 
words 'Horsion" and "rota- 
tion," and they have been used 
interchangeably in the text. 
The German writers distin- 
guish between the two terms 
in a highly technical way, a 
distinction which it does not 
seem desirable to transfer to 
Enghsh. 

VARIETIES OF STRUCTUR.\I. 

SCOLIOSIS (LUIMBAR 

CURVES) 

Lumbar scoHosis exists as 
a simple curve, but more 
often is only one component 
of a compound curve, the 
dorsal curve being, of course, 
in the opposite direction. 
In the Schulthess figures the 
simple lumbar curve formed 
1 1. 7 per cent, of all cases 
treated, and right and left 
curves were of practically 
the same frequency. It 
occurs later than the total scoHosis, as shown by the ages of the 
patients observed. It occurs more frequently in females than in 
males (Scholder: 13.8 per cent, boys, 27.7 per cent, girls. Schulthess: 
6.3 per cent, males, 12.7 per cent, females). The greatest deviation 
from the straight line is most often found at about the second lumbar 
vertebra, and as the lumbar region is short, the curve must be in 
general a sharp one. 

The trunk is displaced to the side of the convexity of the curve and 
the Hne of the waist flattened on that side, while the waist on the con- 
cave side of the curve is sunken in, and folds may form in the skin of 




Fig. 47. — Left Lumbar Scoliosis not 
Returning to the Median Line. 
The lines indicate the median plane and the 
flexibility to each side. 



LUMBAR CURVES 



63 



the flank on this side. This is expressed by an apparent prominence 
and greater size of the hip on the concave side, and it is popularly 
said that one hip has ''grown out" or one hip is ''higher" than the 
other, meaning in anatomical terms that the crest of one ihum is 
more prominent than the other. This inequality of the hips and 
waist-line is the most striking feature of lumbar curves, and unless 
corrected, forms an unsightly deformity in women with prominent 
hips, and makes it necessary to make the skirt longer on one side than 
on the other. The relative height of the shoulders is not noticeably 
affected by lumbar curves. 




It 



B 05>90T 



Fig. 48. — Left Lumbar Curve with 
Slight Right Dorsal Curve. 



Fig. 49. — Left Dorsal Scoliosis. 



As the patient stands, a fullness of the back is noticed in marked 
cases on the convex side of the curve caused by the rotation of the 
vertebrae, which carry the heavy transverse processes around and 
make prominent the overlying structures. In the position of ex- 
treme forward bending the side of the back which is on the convexity 
of the lateral curve is prominent upward, but lumbar rotation is 
always less prominent than dorsal, and to the untrained eye even in 
the severer cases seems slight (Fig. 56). In side bending, mobility is 
greater toward the side which exaggerates the curve than to the side 
which diminishes it (Fig. 61). 



64 



DESCRIPTION AND SYMPTOMS 



DORSAL CURVES 



A single dorsal curve is more frequent than the single lumbar t}^e, 
but is much less frequent than dorsal curves in combination with 
other forms; that is to say, dorsal curves are more often than not 
accompanied by reverse or compensating curves above or below. 
In the Schulthess figures there were 19 per cent, of single dorsal 
curves and 30 per cent, where dorsal curves existed with others. 

The curves are as frequently 
to the right as to the left 
when they exist alone. The 
point of greatest curve is 
from the sixth to the eighth 
dorsal vertebra in tlie major- 
ity of cases. 

In a marked right dorsal 
curve, as seen from behind, 
the thorax is displaced to the 
right, and the right arm 
hangs farther from the side 
than the left; the right 
shoulder is raised and the 
waist-line on the right is less 
concave and much flattened 
in the severer cases, the ribs 
coming close to the crest of the 
ihum and obHterating the 
waist indentation. 
The rotation is made evident 
by a prominence, in the back, of the right side of the thorax, which 
may be seen as the patient stands erect (Fig. 50). Unlike the rota- 
tion in lumbar cases, the rotation element in dorsal cases is a very 
marked feature of the deformity, and a sharp prominence extends 
down the right side of the thorax, composed of the angles of the ribs, 
which pushes the scapula backward and to the right. The left 
side of the thorax as seen from behind is flat or concave, the left 
scapula sunken and rotated with the glenoid cavity displaced 
do\\TLward and the inferior angle inward. A fold in the skin fre- 
quently runs inward and upward from the waist-hne. WTien the 
patient bends forward until the trunk is horizontal, the rotated 
ribs are very prominent upward on the right, and a long arch of 




Fig. 



>o. — Advanced Right Dorsal Scoliosis natural 
IN AN Adult. 



DORSOLUMBAR CURVES 



65 



rib angles is seen which is much more marked than in the stand- 
ing position. On the left side the ribs are sunken and fall away, 
making a flat and even depressed surface to contrast with the 
striking prominence of the right side. 

In a right dorsal curve the right shoulder will inevitably be higher 
than the other unless a left compensating cervicodorsal curve exists 
above it. The absence of a high 
shoulder on the convex side therefore 
should always lead to an examination 
for a compensating curve above. 

As seen from the front, the deformity 
is even more evident, the thorax is dis- 
placed to the right, the right shoulder is 
higher than the left, and the left side 
of the thorax more prominent in front 
than the right. In severe cases the 
lower end of the sternum is generally 
displaced toward the convexity of the 
curve — in this case to the right. The 
contour of the chest is changed, and the 
longest thoracic diameter is the oblique 
antero-posterior line from the point 
rotated backward on the right to the 
point rotated forward on the left — in 
this case from the right scapula to the 
left nipple. This description is, of 
course, to be reversed for left dorsal 
curves. 

The dorsal physiological curve is most often increased, making the 
rounded and distorted back spoken of as kyphoscoliosis (Fig. 51). 
It may, however, be flattened, and even slightly concave forward in 
the dorsal region. Loss of height and shortening of the trunk are 
evident in the severer cases. 

The aspect is wholly different from that seen in lumbar cases, 
where, as has been said, the chief noticeable distortion is in the 
hips and waist-line; in dorsal cases the distortion is most noticeable 
in the thorax and shoulders. 




Fig. 51. — Kyphoscoliosis. 



DORSOLUMBAR CURVES 

Dorsolumbar scoliosis is a form seen as a simple curve with con- 
siderable frequency (20 per cent.), being, therefore, much more com- 



66 



DESCRIPTION AND SYMPTOMS 



mon than simple lumbar, but about as frequent as simple dorsal 
scoliosis. It naturally partakes of the character of the two forms 
just described and affects nine females to one male. The seat of 
greatest curve is generally at the dorsolumbar junction. It is four 
times as frequently convex to the left as to the right. The trunk and 

lower thorax are displaced 
toward the side of the con- 
vexity of the curve and over- 
hanging the pelvis, and the 
waist-line on that side is 
flattened or obhterated, while 
on the concave side the outline 
cuts in sharply above the 
pelvis, frequently forming 
folds in the skin. The atti- 
tude is more like that of an 
exaggerated total scohosis 
than Hke either the dorsal or 
lumbar form. It is not so 
prone to be associated T\dth 
compensatory curves as are 
the other forms. 

CERVICODORS.\L CURVES 

Cervicodorsal scohosis is a 
comparatively rare form of 
the deformity, occurring in 
only 3.6 per cent, of all cases. 
It is convex to the left more 
often than to the right in the 
relation of 3 to 2, and the 
greatest curve is most frequently located at the third or fourth 
dorsal vertebra. The head is carried forward and tipped to the 
concave side of the curve. The neck is obviously shortened, and the 
outline from the base of the skull to the shoulder is fuller and less 
crescentic in outhne on the convex side of the curve than on the 
other. The shoulder on the convex side of the curve is raised and the 
other lowered, and the scapula of the raised side is conspicuously 
higher. The arm of the convex side hangs farther from the side 
than the other. The rotation appearances are marked, and the 
sharp angles of the upper ribs are prominent in the lower part of 




Fig. 



-Left Dorsoll-mbar Scoliosis. 



COMPOUND STRUCTURAL CURVES 



67 



the curve, while above the rotation is less evident because there are 
only the transverse processes of the cervical vertebrae to make a 
projection. The trunk is displaced to the side of the convexity of 
the lateral curve. 



COMPOUND STRUCTURAL CURVES 

The pictures of compound curves cannot, of course, be as simple 
or uniform as those of the simple types. A right dorsal left lumbar 




Fig. S3. — Cervicodorsal Curve Due 
TO Defective Ribs And Malforma- 
tion OF Vertebra. 



Fig. 



54. — Right Dorsal Left Lumbar 
Scoliosis. 



curve, for example, will present a combination of the appearances 
described in both dorsal and lumbar curves; a right cervicodorsal left 
dorsolumbar, the sum of the pictures of the two factors. If the 
dorsal element predominates, the appearances will be more dorsal 
than lumbar, as is usually the case, and every grade of variation is to 
be seen, the predominant curve setting its stamp on the clinical 
appearance. The right dorsal left lumbar curve is the one most 
frequently seen. Dorsal scoliosis with compensating curves formed 
30 per cent, of all cases in the Schulthess tables, and of these the 



68 DESCRIPTION AND SYMPTOMS 

dorsal curve was to the right in 80 per cent, of the cases. The great- 
est point of curve in these was from the sixth to the eighth dorsal 
vertebra, and the most frequent reverse curve associated was in the 
lumbar region. It is a type of curve most frequently seen in older 
children, the bulk of the cases being from ten to sixteen years old, 
but it may be seen in very young children. The increased suscepti- 
bility to compound curves with increasing years is sho"v^m by Schol- 
der's statistics of school children: 

8 years old 0.4 per cent. 

9 years old i . i per cent. 

10 years old 1.2 per cent. 

1 1 years old 2.4 per cent. 

T2 years old. 2.1 per cent. 

13 years old s-s per cent. 

14 years old 3.3 per cent. 

Women are more frequently affected than men, the proportion 
being 7 to i. 




Fig. 55- — Dorsal Rotation Shown by Fig. 56. — Luimbar Rotation Shown by 
Prominence of Right Side in Bending Prominence of Left Side in Bending 
Forward. Forward. 

The appearances shown in the illustration (Fig. 54) will serve to 
demonstrate how the appearances of two t^'pes of simple scoHosis are 
brought together in the same patient. In a right dorsal left lumbar 
curve, the appearances of the thorax are those described for a simple 
dorsal curve, but the overhang of the thorax is modified by the dis- 
placement of the lower trunk in the opposite direction incident to the 
left lumbar curve. The resultant position may be, as in the simple 
curves, either accompanied by an increase or diminution of the 
physiological curves. 

That scoliosis may change from one clinical picture to another in 



COMPOUND STRUCTURAL CURVES 



69 



the same patient in the course of years is well established. Not only 
does the total curve frequently change to a compound type as men- 
tioned, but structural curves change the body outline most fre- 




FiG. 57. — Severe Dorsal Rotation on Right Side in Forward Bending. 




Fig. 58. — ScHULTHESs' Tracing of a Girl Six Years Old. — {Schulthess.) 
Fig. 59. — Tracing of the Same Case Eight Years Later. — {Schulthess.) 



quently by the addition of compensatory curves. In general, how- 
ever, the later distortion is an exaggeration of the earlier. 



70 DESCRIPTION AND SYMPTOMS 

The relative frequency of the common types as tabulated in 1137 
cases coming for treatment by Schulthess was as follows: 

Total scoliosis. 15 • 39 per cent. 

Lumbar 11. 7 per cent. 

Dorsal. 19.0 percent. 

Dorsolumbar 20.0 per cent. 

Cervicodorsal 3.6 per cent. 

Compound 30 . o per cent. 



CHAPTER VI 
EXAMINATION AND RECORD OF SCOLIOSIS 

In undertaking the examination of a case of scoliosis it is important 
to obtain a fairly complete history of the child's early life, as throwing 
light on the cause of the deformity, and secondly, as giving informa- 
tion as to the child's condition at the time of beginning treatment, as 
indicating the probable resistance to fatigue, the existence of factors 
likely to complicate treatment, etc.; and, also, it is important to ob- 
tain as accurate a record as possible of the curve at the beginning 
of treatment and at subsequent stages. These two matters will be 
dealt with in the order named. 

History. Family History. — The occurrence of scoliosis in other 
members of the family is of interest as possibly indicating a heredi- 
tary origin. A tuberculous family history would make one particu- 
larly careful about the child's hygiene. 

Personal History. — The character of the labor if difficult may 
point to the possibility of some injury occurring at birth. The 
health of the child as a baby, whether it was bottle fed or nursed, and 
the date of the first teeth are important in their bearing on rickets, as 
are the existence of bowlegs, rosary, or other signs indicating rickets. 
The history of acute illnesses in childhood are significant in showing 
whether the child has been sickly or not, and any mysterious feverish 
attack may have been infantile paralysis. The age at which the 
curve was noticed and its subsequent progress are proper subjects 
of inquiry, but the information obtained is rarely reliable. 

It is important to note the child's mental make-up, whether nerv- 
ous and apprehensive or easy going and careless, as it has a bearing 
on the formulation of treatment. Evidences of overwork at home 
or at school are factors of importance. 

The height and weight should be taken, first to show whether there 
is a reasonable period of growth ahead of the individual child, and 
second, to show whether the child is backward in growth or decidedly 
oversize. Great excess of height or weight, or of both, is important 
because decidedly overgrown children as a rule show diminished 
resistance to physical exercise and seem particularly liable to defects 
of posture. The height and weight should be taken and compared to 
the average given in the table. 

71 



72 : 


EXAMIXATIOX 


AND RECORD 


OF SCOLIOSIS 






\vERAGE Heights and Weights. - 


-(r. J/, Rotch) 




Boys 


Girls 


Height, 


Weight, 


Age 


Weight, 




Height, 


inclies 


pounds 




pounds 




inches 


19-75 


7-15 


birth 


6.93 


1. 
1 

! 


19-25 


24-75 


14 


30 


5 mos. 


13.86 




23-25 


29-53 


20 


98 


I year 


19.80 




29.67 


33-82 


30 


36 


2 years 


29.28 


! 


32.94 


37.06 


34 


98 


3 years 


33-15 




36.31 


39-31 


37 


99 


4 years 


36.36 


I 


38.80 


41-57 


41 


00 


5 years 


39 -5^7 




41.29 


43-75 


45 


07 


6 years 


43-18 




43.35 


45-74 


48 


97 


7 years 


47-30 




45-52 


47.76 


53 


81 


8 years 


51-56 




47-58 


49-69 


59 


00 


9 years 


57.00 




49-37 


51.68 


65 


16 


10 years 


62.23 




51-34 


53-33 


.70 


04 


1 1 years 


68.70 




53-42 


55-11 


76 


75 


12 years 


78.16 




55.88 


57-21 


84 


67 


13 years 


88.46 




58.16 


59-88 


94 


49 


14 years 


98.23 




59-94 



The weight at birth, and in the first, second, and third years, 
were without clothing. The ordina'ry school clothes were worn in 
the weighing from five to fourteen years. As the tables were made 
up from children in the public schools, children in private practice 
will as a rule exceed these figures. 

EXAMINATION 



GEXER.AL COXDITIOX 

In the examination it is important to note the nutrition and devel- 
opment, that is, whether the child is fat or thin, flabby or firm, pale 
and anemic or of good color and apparently robust. The nervous 
condition of the patient may be estimated by the presence or absence 
of apprehension, cr\dng, twitching, or tremor, but restlessness in 
young children means nothing. The condition of the heart should 
always be examined because otherwise, harmful exercise might be 
prescribed for a child with organic heart disease. The following 
points should also form part of a routine examination. 



EXAMINATION OF SPINE 73 

Condition of lungs and chest expansion. Comparative length of 
legs. The existence of flat-foot or "weak ankles." Whether or not 
spectacles are worn. General gait and carriage. Manner of sup- 
porting the .underclothes and stockings, whether objectionable 
or not. 

EXAMINATION OF SPINE 

A patient with suspected lateral curvature should always be ex- 
amined with the back wholly bare. The clothes should be firmly 
pinned or fastened by a strap around the hips at a level low enough to 
show the top of the cleft between the buttocks and to show the out- 
line of the pelvis. In children the patients should be stripped to this 
level; in adolescent and adult young women the chest should be cov- 
ered by an apron hanging over the front of the thorax, the strings of 
which are fastened around the neck. 

The patient should stand, back to the surgeon, squarely on both 
feet with the arms hanging at the sides. It is desirable to allow the 
patient to stand quietly for a minute or two before beginning the 
examination in order to secure the fatigued or relaxed position which 
is the characteristic one. The patient should not be handled or 
touched during the first inspection, as the contact of the hand fre- 
quently stimulates the muscles and negatives for the time being the 
relaxed position. * 

Inspection of the natural standing position forms the first step 
in the examination. The surgeon notices first: 

I. The body outline, whether symmetrical or not, comparing on 
both sides the outline from the axilla to the crest of the ilium, 
whether one is flatter or more curved than the other. The trained 
eye estimates this asymmetry as a lateral displacement of the thorax 
or trunk with regard to the pelvis, and it is the safest guide. The 
appreciation of symmetry or the absence of it is essential in giving 
corrective gymnastics, and the most useful method to one trained is 
to erect an imaginary perpendicular from the cleft between the 
buttocks (anal fold), and estimate whether it cuts the trunk in the 
middle or whether more of the trunk lies to the left or right of it. 
It is obvious that if any part of the spine is laterally curved, it must 
carry with it a segment of the body to the right or left. This 
displacement will be accompanied by a change of body outline, and 
a difference in body outline on the two sides is presumptive evidence 
of a lateral curve. The outline of the body and displacement of tlie 



74 EXAMINATION AND RECORD OF SCOLIOSIS 

trunk to one side may always be seen more plainly from the front 
than the back, as the outhne is sharper. In children this method 
should follow the one described. 

2. The surgeon next notices the level of the shoulders, whether 
one is higher than the other, and whether this is a constant position. 
The elevation of one shoulder is generally a sign of lateral curvature, 
but may rarely exist with no perceptible curve. 

3. The position of the scapulae should then be noted and the two 
sides compared. It is not of primary importance, but it is desirable 
to note their relative distance from the spine, whether one or both of 
the scapulae are displaced forward, and whether /any rotation of the 
bone has taken place. 

4. The habitual position of the head should be noted, whether 
tipped to one side or held constantly rotated. 

5. The antero-posterior ph3^siological curves should be investi- 
gated and any increase or diminution of the dorsal or lumbar curves 
noted. 

Estimation of the Spinal Curve. — Over the middle of each spinous 
process a mark is then made on the skin by a flesh pencil or by ink 
while the patient stiU stands as described. The skin must not be 
drawTi to one side or the other in making these marks, or distortion 
may be caused by the movements of the skin over the bony points. 
This line of marks is accepted as representing the spinal curve, al- 
though it does not accurately represent the position of the bodies of 
the vertebrae (see Pathology) . If a curve is present, the line of marks 
will be evident as a curved in^ead of a straight line, for a normal 
spine shows a hne of marks forming a straight line which lies in the 
median plane of the body. 

There are now two questions to be answered: (i) Is lateral curva- 
ture present? (2) If present, what sort of a curve is it? 

The median plane of the body is readily determined by holding a 
plumb-line behind the patient, the lower part of which passes through 
the cleft between the buttocks. In the normal spine each mark 
will lie under this plumb-line. The deviation of any number of 
spinous processes from this line represents a lateral curve. This 
method of erecting a perpendicular from below is preferable to the 
method of dropping a plumb-Hne from the top of the column (the 
Beely-Kirchoff method). 

If a curve exists, as shown by the plumb-line, the second question 
arises as to what sort of a curve it is, whether functional or structural. 

Functional curves have four definite attributes which should be 



EXAMINATION OF ROTATION 



75 



looked for (see p. 55), and in the absence of any one of them (except 
for the occasional absence of rotation on the concave side in the 
forward bent position) the diagnosis of a functional curve cannot be 
made; under these conditions the case is, therefore by exclusion, 
structural. The curve is then described (p. 61). 

Cervical curves must be roughly estimated by the eye, for on 
account of the inaccessibility 
of the cervical spinous pro- 
cesses and the instability of 
the head, they cannot be 
definitely measured. 

Estimation of Rotation or 
Twist.— The surgeon, having 
thus recognized any bodily 
asymmetry and having identi- 
fied and defined the curve, is 
in a position to investigate 
the element of rotation or 
twist which is essential in 
every case. 

The surgeon, standing close 
behind the patient, looks 
down on her shoulder-girdle 
from above to estimate 
whether it is in the same 
lateral plane as the pelvis or 
whether twisted forward on 
one side and back on the 
other. This is of use chiefly 
in postural cases, and in 
structural cases is of little 
value. By sighting the 
scapulae and back of the 
thorax on the buttocks it is easily seen whether any twist of 
the thorax has occurred in relation to the pelvis. Evidence of 
rotation of the ribs or lumbar transverse processes backward on 
the convex side of the lateral curve, which accompanies structural 
cases, will in severe cases be evident in the standing position, but 
it is generally examined for and estimated in a position of forward 
flexion of the trunk, sometimes spoken of as Adams' position. 
The patient bends forward until the trunk is horizontal with the arms 




EiG. 60. — The Plumb-line in the Cleft of 
THE Buttocks to Determine the Median 
Plane of the Body. 



76 EXAMINATION AND RECORD OF SCOLIOSIS 

hanging down and the knees not flexed. In this position the patient 
remains while the surgeon glances along the back from behind or in 
front, with his head on a level with the spine, and looks to see whether 
either side of the trunk is more prominent upward in the lumbar, 
dorsal, or cervical region. Any such upward prominence represents 
rotation or twist and is a most important matter. If it occurs on 
the concave side of the lateral curve and involves the curved region, 
it will be slight and evenly distributed through the spine and desig- 
nates a functional or postural curve. That is, in a left total postural 
curve the right side of the back will probably be more prominent 
upward in the forward bent position. 

If it occurs as a well-defined local upward prominence occupying 
the curved region, it designates a structural curve at that location, 
the curve being convex to the side on which the prominence occurs 
and occupying the same anatomical area. That is, a right dorso- 
lumbar upward prominence designates a right dorsolumbar struc- 
tural curve. This must be clearly understood, for at times a curve 
which is obscure or confusing in the upright position is cleared up by 
a recognition of its rotation as seen in the forward bending position. 

Estimation of Spinal Flexibility. — The patient should now lie on 
the face and the position of the spinous processes be noted. The 
marks on the skin will represent the curve of the spine in the erect 
position, and any straightening of the spine in recumbency will be 
shown by finding that the spinous processes form a less curved line 
than that marked on the skin. In postural curves the spine will be- 
come straight in recumbency, while structural curves will be per- 
ceptibly straighter than when the patient is erect. The patient 
should now be suspended by a Sayre head shng, enough to take the 
weight off of the spine, and the straightening of the spine noted. 
This modification of the asymmetry of the trunk by suspension is 
important and should be carefully studied as to whether the asym- 
metry is practically unchanged, whether the overhang of the thorax 
is corrected, and whether the patient becomes wholly symmetrical. 
The position of the patient in suspension represents the maximum 
that may be expected from treatment in that individual case until 
further flexibility is restored by treatment directed to that end. 
The restoration of complete or almost complete symmetry by sus- 
pension points to an early case and one amenable to treatment, for 
one of the early changes in structural curves is a stiffening of the 
curved region of the spine which causes the persistence of the curve 
under suspension. So far as possible it should be noted whether the 



X-RAY 77 

improvement in symmetry is produced by a straightening of the 
curve or curves or whether the modification in asymmetry is pro- 
duced by the other parts of the spine. For example, in a dorsal 
curve is the relation of the curved region changed or is the curved 
part simply pulled away from the pelvis by a stretching out of the 
lumbar region? 

The patient should then bend forward to determine normal flexi" 
bility forward. The average child can touch the floor with the fin- 
gers while the knees are straight, while in adult life less flexibility 
is obtained. 

The flexibility of an individual spine is a matter determined by 
age, habit, and individual peculiarity. To know in a general way 
what the normal flexibility at a given age should be, is important in 
children, but in adults it is so much a matter of individual habit that 
it is of less importance. One man of fifty, for example, who has 
taken exercise may be able to touch the floor with his hands in for- 
ward bending, while another man of the same age of sedentary life 
cannot get his finger-tips within a foot of the floor in the same posi- 
tion, yet both spines are to be classed as normal. How rapid the 
change in flexibility may be owing to exercise is shown by the case of 
a healthy boy of fifteen who could not touch the floor with his finger- 
tips in forward bending. He injured his knee and was obliged to 
wear a ham-splint. The exertion necessary to dress himself with his 
leg stiff so increased his forward flexibility that in ten days he could 
place the palms of his hands on the floor without exertion in forward 
bending. 

The patient then stands with the elbows directed outward the 
hands clasped behind the neck, and bends to one side and to the other. 
The characteristics of side bending have been fully described, and 
modifications and restrictions of this are to be studied. Patients with 
curves can, as a rule, bend better to the side that exaggerates the 
curve than to the side that diminishes it. 

The examination has been dealt with thus at length because 
rational treatment cannot be undertaken without a clear formulation 
of the character of the deformity, and experience shows that in the 
loose use of terms and in slipshod examinations certain failures to 
obtain proper results from treatment have their origin. 

X-ray. — The :r-ray is of use in showing: (i) the existence of bony 
defects, numerical variation, or other anomalies of the spine; (2) the 
degree of distortion of the individual vertebrae; and (3) the degree 
and character of the curve. The results of .v-ray photographs do not 



78 



EXAMIXATIOX AXD RECOEJ) OF SCOLIOSIS 



as a rule agree with the dinical appearances, the amount of curve 
in the .v-ray being generally more than is indicated bv the marks 
over the spinous processes. The amount of rotation is indicated in 
the .r-ray by the position of the shadow of the spinous processes in 




Fig. 6i. — Patiext v.ith a Right Dctrs-AX Left Lumbar Strvctltial Cur\'e Bexdixg 
TO THE Left and Right, Showixg the Comparatu'e Rigidity of the Ll-mbar Region 
TO Left Bexding and of the Dorsal Regiox to Right Bekdikg. 



relation to the shadows of the bodies, normally the spinous process 
appearing in the middle of the body. But the element of distor- 
tion in .r-rays must be remembered. A patient is likely to be twisted 

by lying on the back if rotatior is present, and any de^'iation of the 



RECORD OF SCOLIOSIS 79 

tube from the middle line of the body is expressed as distortion of 
the vertebrae, yet x-rsiys to-day, taken under proper conditions, 
afford the best and most reliable index of the degree of the curve and 
progress under treatment, for reasons explained on p. 77. 

RECORD 

An accurate and simple method of recording scoliosis would be of 
great value to the general practitioner and to the specialist, but no 
such method exists to-day, although many have been described and 
advocated. The x-rsiy taken under the conditions described above 
is probably the most accurate at our disposal. Photography is an 
easy means of record, but does not fairly represent the position of 
the spine and simply gives the body outlines, and we shall see that 
a photographic overcorrection may be obtained with little or no 
change in the spine, etc. (ref. p. 167). So we must remember the 
limitations of photography, and that in the severer curves it may 
mislead us wholly as to progress, but it is fairly accurate as a rough 
method for the recording of bodily asymmetry caused by scoliosis. 
In taking photographs the following rules must be observed : 

I. The patient must stand at ease with the legs straight and the 
arms hanging at the sides in the relaxed position. 2. The heels of 
the patient must be on a line parallel to the lens, otherwise distortion 
is inevitable. 3. The patient must stand at a fixed distance from 
the camera in all cases if pictures are to be used as accurate records. 
4. The light should be oblique from behind, preferably diffused, and 
not the direct light of the sky if possible, which gives too violent con- 
trasts between light and shadow. A light from overhead throws 
the shadow of the shoulders onto the back and obscures the spinal 
furrow. A light directly from behind gives a flat white picture with- 
out contours. A light directly from the side throws the shaded part 
of the body into such blackness that the body outhne of that side is 
lost. A crossed light obliterates contour and gives a flat and con- 
fusing picture. 5. The shadows should be diminished by a white 
reflector on the side of the patient away from the light. By this 
arrangement contour may be secured in the picture. 6. The un- 
steadiness and swaying of the patient may be obviated in a measure 
by placing an ordinary photographer's rest against the chest. 

A photograph of rotation may be obtained by having the patient 
bend forward with the head away from the camera and focusing on 
the part of the back affected by the rotation. 



8o 



EXAMINATION AND RECORD OF SCOLIOSIS 



If it is desired to measure and study the curve from the. finished 
photograph, the method devised by Fitz may be used.^ 




Fig. 62. — ^Leveling Apparatus (Nivellier Trapez) for the Measurement of Rotation 
IN the Forward Bent Position. — {Schulthess.) 




Fig, 63. — Schulthess' Measuring Apparatus. 

Various modifications of the simple photographic method by 
means of screens, standard positions, etc., have been devised,^ of 

1 G. W. Fitz: "Bos. Med. and Surg. Jour.," Nov. 16, 1905. 

2 "Festschrift fiir J. Berg." "Nordiskt medicinskt. Arkiv.," 191 1. 



RECORD OF SCOLIOSIS 



8l 



which that of Bucholz and Osgood seems simple and accurate,^ but it 
must be remembered with regard to these that the photographic 
method possesses, and always will possess, an intrinsic inaccuracy as 
explained. 




at. 



21.. 




Fig. 64.- 



-Tracing of a Left Dorsal Right Lumbar Curve Made by the Schulthess 
Measuring Apparatus. — {Children's Hospital.) 



Tracing. — A simple and approximately accurate record may be 
made by marking the spinous processes and laying on the back, while 
the patient stands erect, a strip of crinoline gauze, through which the 
spinal marks may be seen. They are thus easily marked on the 
gauze, which may be kept as a record. The error lies in the possible 
slipping of the gauze and the necessity of placing the hands on the 
patient. 

Any one interested in the subject may find a number of methods 
described, together with the literature of the subject, in the reference.- 

1 Am. Journ. Orth. Surg.," xii, 1914, 77. 

2 "Ueber die Messmethoden des Ruckens," Hovorka, Wicn, 1904. 



82 EXAMINATION AND RECORD OF SCOLIOSIS 

Rotation may be estimated in degrees with accuracy in the forward 
bent position by means of the Schulthess level square (Nivelher 
Trapez), which consists of two arms sliding on a rod to which they are 
at right angles. These arms are placed on corresponding levels of the 
back at equal distances from the spine, and the rod is provided with 
a protractor and swinging weight to show the inchnation of the rod 
to the horizontal plane in degrees (Fig. 62). 

^lethods which would estimate the rotation while the patient lies 
prone on the face are inaccurate, because the pressure of the table on 
the prominent side of the front of the thorax tends to rotate the chest 
and cause distortion. 

The Schulthess Apparatus for the Record of ScoHosis. — The 
Schulthess apparatus, which has been generally accepted in Europe 
as being the most accurate means of record at our disposal, consists of 
an upright frame in which the patient stands, the pelvis being fixed 
by clamps and the sternum steadied by an adjustable rod. Behind 
the patient there is a sHding bridge T\dth counterweights which move 
up and down on the uprights. Attached to this bridge is a pointer 
which moves forward and backward and sideways. The movements 
of this pointer by an arrangement of weights and pulleys are recorded 
upon two glass panels parallel to the sagittal and frontal plane of 
the body by means of pencils moving on paper attached to the glass 
panels. By tracing from below upward the marked lines of spinous 
processes on one panel, the antero-posterior curve of the spine is 
recorded, while on the other the lateral curve is simultaneously 
marked. 

By a longer pointer the lateral body outline is then traced in the 
frontal plane after the position of the scapulae has been recorded. 
The two pencils in use are then thrown out of action, and by means 
of a third pencil working upon a glass plate on the sliding bridge 
horizontal contours are recorded at three levels. By means of an 
additional sHding bridge working in front of the apparatus a late 
modification of it provides for anterior as well as posterior contours, 
which may be joined to give a complete contour of the body at 
different levels (Fig. 63). 

The apparatus is expensive and complicated, and its successful 
use demands much training. 



CHAPTER VII 
PATHOLOGY 

The pathological changes in the vertebral column to be described 
as existing in scoliosis consist of modifications in shape and structure 
of the bones and soft parts. In addition to these there are found at 
times congenital anomalies of the vertebrae, changes due to rickets, 
the pathological results of empyema and infantile paralysis, all of 
which are to be regarded as primary and causative of the changes to 
be described. In other cases no pathological changes in addition to 
those described are to be found. These matters will be discussed 
more fully in speaking of etiology. 

The pathological changes occurring in scoliosis may vary from 
moderate asymmetry to extreme distortion. In general, the spine 
is curved to one side in some part of its length, or it is curved in one 
direction in one part, and in the opposite direction above or below or 
both above and below. These curves are formed by the deviation 
of the vertebrae from the median sagittal plane of the body and are 
more marked in the column of bodies than in the column of arches. 
The lateral curve may be a general sweep to one side, or it may be 
sharp and in the severer cases angular. In the severer cases it exists 
not alone in the presacral vertebrae, but may also involve the sacrum 
and coccyx. 

In addition to the lateral deviation, the curved region is rotated or 
twisted on a vertical axis, the bodies of the vertebrae always turning 
toward the convex side of the lateral curve. This rotation is the me- 
chanical accompaniment of the lateral curve, and one cannot exist 
without the other, although in some cases the rotation is out of pro- 
portion to the lateral deviation, and in other cases the lateral curve 
predominates over the rotation. 

In connection with the lateral curve, alteration in the normal 
antero-posterior physiological curves may occur, as mentioned. The 
relation of these changes to the lateral curve is but little understood. 

Such being the gross pathological changes occurring in the spine as 
a whole, it will add to clearness in considering this most complex mat- 
ter to take up individually the alterations in the separate elements. 

83 



84 



PATHOLOGY 




Fig. 65- — Scoliotic Spine from the Dwight Collection of Abnormal Spines in the 

Warren ^Museum. 
Sacralization of the twenty-sixth vertebra on the right. Thirteen dorsal and six lumbar 
vertebras. Fusion of several vertebrae and of first three ribs ; on the left. The changes in 

the vertebral bodies are characteristic of severe scoUosis. 



CHANGES IN THE VERTEBRA 85 

CHANGES IN THE VERTEBRA 

Vertebral Bodies. — The scoliotic vertebrae are to be divided into 
two classes, according to their pathological changes, those in the 
angle of the curve being called wedge vertebrae, while those between 
the apices of the curves or between the apices and the normal portion 
are called lozenge-shaped or oblique vertebrae. Pure forms of wedge- 
shaped and lozenge-shaped vertebrae are rare, and both processes 
are common in the same vertebra. 

A certain amount of rotation and also a transverse displacement 
of one vertebra upon another is normally possible up to a certain 
degree on account of the elasticity of the intervertebral discs and the 





Fig. 66. — A "Wedge" Vertebra. — 

(Schulthess.) 
Second lumbar seen from in front; left 
lumbar curve. 



Fig. 67. — An "Oblique" Vertebra. 

(Schulthess.) 

Fourth lumbar seen from the front; 

from a left h:mbar curve. 



play of the ligaments, but early in the affection the pathological 
process is not satisfied with the normal excursions, but rotates the 
vertebra in its structure. This rotation is expressed in the relation 
of the upper and under surfaces of the vertebral body and in a twist 
between the body and arch. 

Wedge Vertehrce. — The vertebrae at the apex of the lateral curve and 
just above and below it, firom one to five in number, are called the 
wedge or apex vertebrae (Keil-wirbel or Scheitelwirbel), and are com- 
pressed on one side and consequently wedge-shaped. The obliquity 
may affect chiefly the upper surface when the vertebrae are below the 
apex of the curve, and the lower surface chiefly when they are above 
it, but it may affect both upper and lower surfaces nearly equally, as 
in the vertebra at the point of the curve, and some modification of 
both surfaces is generally to be noted. The thinnest part of a wedge 
vertebra is found on the side of the concavity of the lateral curve and 
generally toward the posterior aspect of the body. The side of the 



86 PATHOLOGY 

body toward the concavity is broadened and lipped in severe cases, 
and synostosis between two vertebral bodies may occur in this loca- 
tion. The apex vertebrae are rotated, as a whole, toward the con- 
vexity of the lateral curve. 

Lozenge-shaped Vertehrce (torsion vertebrae, oblique vertebrae, Inter- 
ferenz-wirbel or Schrag-^-irbel). — The vertebrae between the apex ver- 
tebrae of the two curves or between the apex vertebrae and normal 
vertebrae are deformed in a somewhat different manner. The upper 
surface of the vertebra is displaced on the lower in such a way that 
the outline of the vertebra is lozenge-shaped, the longest diagonal 
axis being toward the apex of the lateral curve, the top of the verte- 
bra being moved sideways on the bottom. Such vertebrae may 
show oblique ridges on the front of the body. The upper part of the 
body, moreover, twists on the bottom part, below a right dorsal 
curve, the upper part of the vertebra twisting in the same direction as 
would the hands of a watch, while above the apex of the curve the 
twist occurs in the opposite direction. This is called longitudinal 
torsion. 

The vertebral foramen in the dorsal region, instead of being round 
as in the normal, in severe scoliosis becomes pointed at the side 
toward the concavity. In the lumbar region the normal triangular 
shape is distorted by being irregularly blunted at the angle on the 
side of the concavity. 

Arches of the Vertebrae. — Pedicles. — In the wedge vertebra the 
original elevation of the pedicles may be retained. As a rule, they 
are lowered on the concave side of the curve and tend to be more 
oblique on the convex side, but in the vertebra at the point of the 
curve they may be alike on the two sides. The pedicle on the convex 
side is directed straight backward and the other backward and 
outward. In the dorsal vertebrae the pedicle of the concave side may 
be narrowed, but in the lumbar region it is more generally broadened 
and the transverse process becomes smaUer. In the lozenge verte- 
brae below the apex the pedicles are likely to be depressed and above 
it elevated, according to the intensity of the curve. In severe scolio- 
sis the shortening of the trunk is so great that the vertebrae are 
pressed together, and, as the bodies offer less resistance to compres- 
sion than the arches, the displacement of the pedicles on the bodies 
is brought abojat. 

Articular Processes. — The articular processes being connected with 
the pedicles share in any change ttat they undergo. 0\\ing to the 
fact that the joint planes are so different in the dorsal and in 



CHANGES IN THE VERTEBRA 87 

the lumbar regions the pathological appearances differ widely in the 
articular facets of the dorsal and lumbar vertebrae. The crowding 
together of the articular processes on the concavity of the lateral 
curve results in an enlargement, deepening, and broadening of the 
joint surfaces, while on the convex side the facets are smaller and 
higher. In the lumbar region the superior articular facets on the 
concave side are hollowed out, while the inferior ones are correspond- 
ingly prominent and rounded, and the cartilage is thickened on the 
concave side. The involvement of these joints is a matter of some 
practical importance, and the changes suggest an adaptation to 
greater demands on the joints on the concave side of the column. 
Synostosis may occur in these joints, and the ligaments may share 
in the ossification. 

Transverse Processes. — The transverse processes tend to remain 
more horizontal than the body of the affected vertebra, and as the 
vertebra becomes inclined to the horizontal plane by the changes 
described, the transverse processes strive to remain as nearly hori- 
zontal as possible. Not infrequently the transverse processes are 
shorter and thicker than normal on the convex side above and below 
the apex of the curve. 

Spinous Processes. — The spinous processes are deflected toward 
the convexity of the lateral curve in the dorsal region. This, it 
seems, may be explained as being the natural position when the spine 
is laterally curved and is retained in a scoliotic position under the 
effect of muscular pull, while the bodies of the vertebrae, being 
influenced largely by weight bearing, individual plasticity of bone, 
and certain unformulated conditions, are forced, as has been said, 
from the concavity to the convexity of the curve. 

In the lumbar region in severe cases the spinous processes are 
diverted toward the concavity. This deviation, it would seem, is 
the result of a moving to the side of the root of the spinous process 
from extreme rotation, as the tips of the processes show the endeavor 
to conform to the usual position by being in some degree approxi- 
mated to the convexity of the curve. In the dorsal region the spin- 
ous processes are also displaced downward, and the direction of each 
spinous process is therefore influenced by its contact with the one 
below it. 

The angle between the lower border of the spinous process in this 
region and the arch becomes on the convex side smaller and on the 
concave side larger than normal, and the appearance of displacement 
to the convex side is thus increased. If the arch is displaced hori- 



88 PATHOLOGY 

zontally upon the vertebral body, as described above, by the lower- 
ing of one pedicle and the elevation of the other the spinous process 
undergoes a rotation around its own longitudinal axis. The irregu- 
larity of these appearances may be explained by the pull of the mus- 
cles, a matter which is at present imperfectly formulated. 

Joints between Vertebrae and Ribs. — These, of course, are of two 
kinds: first, the joints between the heads of the ribs and the sides 
of the vertebrae; second, the joints between the tubercles of the 
ribs and the transverse processes. These are both similarly affected 
in severe scoliosis, being deepened on the side of the convexity and 
faintly indicated on the side of the concavity, especially above the 




Fig. 68. — Distorted Antero-posterior Plane of a Scoliotic Vertebra. — (Riedinger.) 

apex of the curve. The articular facets on the side of the vertebral 
body are moved forward on the concave side and backward on the 
convex side. 

INTERVERTEBRAL DISCS 

These show the earliest changes, and at the points of greatest 
curve are compressed and project beyond the edges of the vertebral 
bodies as if the bodies had grown into them. On the convex side 
they are thicker than on the other. 

LIGAMENTS 

On the side of the concavity the anterior common ligament is dense 
and thick, while on the convex side of the curve it is thinned and 
shows no definite lateral border. In the lozenge-shaped vertebrae the 



MUSCLES 



89 



fibers run obliquely in a direction corresponding to the ridges on the 
anterior surface of the vertebral bodies. The posterior common liga- 
ment near the apex is found more to the convex side than normal 
because its insertions into the intervertebral discs do not share in the 
broadening out of the concave side of the vertebral bodies, and the 
vertebra thus grows to the concave side, while the ligament remains 
more nearly in the middle. The ligaments connecting the heads 
of the ribs and the spine are long and atrophied on the convex side 
and short and tense on the concave side. 

MUSCLES 

Where muscles are thrown out of use they atrophy and may 
undergo fatty or fibrous degeneration. When increased demands are 
made upon them they hypertrophy When under changed condi- 
tions they pass over a surface of bone they may become tendinous 




Fig. 69. 



-Horizontal. Section of Scoliotic Cadaver Mid-dorsal Region. 
Medical School.) 



{Harrarc 



where the contact occurs. Nutritive or adaptive shortening occurs 
when the ends of muscles are approximated. All these changes are 
to be found in cases of severe scoliosis, but the muscular changes in 
slight scoliosis have not been formulated. 

The change which muscles undergo in lateral curvature is first of 
all a change of direction of pull caused by the displacement of the 



go PATHOLOGY 

thorax in relation to the pelvis toward the right or left. For exam- 
ple, if the trunk is displaced toward the left, the muscles taking origin 
from the crest of the ihum are directed toward the left at their inser- 
tion in the spine. Under normal conditions the contractility of the 
muscles would be sufficient to bring them back to their normal posi- 
tions, but in a strong lateral inclination of the lumbar segment above 
the sacrum the psoas muscle, for example, acquires a broad insertion 
and becomes fan-shaped, thereby assuming a different function. 
Under normal conditions the insertion of this muscle is more linear 
and placed at an acute angle to its direction of pull. 

Following the impairment of function of the muscles on the con- 
cave side of the lateral curve, in severe cases fatty degeneration is 
observed. On the convex side the muscles are wasted and thin, and 
sometimes, in exceptional cases, fatty degeneration is found here also. 
On the convex side more often a fibrous degeneration is found; that 
is, atrophy of the muscular tissue and the formation of larger ten- 
dons. In addition to all of this the stiffness of the column, which 
sets in fairly early in moderate and severe grades of scoliosis, tends 
to cause atrophy of the muscles of the back in general, the atrophy of 
disuse. 

The diaphragm assumes an oblique position and is lower on the 
side of the convexity of the dorsal curve. If the apex of the dorsal 
curve is situated high up and associated with kyphosis, the top of the 
diaphragm may be much elevated — even as high as the level of the 
third rib. 

THORAX 

In lumbar scoliosis the changes in the thorax are slight, but some 
rotation of the structure as a whole is noted in relation to the frontal 
plane of the pelvis. 

In dorsal scoliosis the thorax is not only displaced as a whole 
toward the convexity of the curve, but its structure is distorted. 
The thorax as a whole tends to retain its normal position with regard 
to the frontal plane of the body more closely than does the spine, 
which, as it were, rotates in the thorax. It thus undergoes a twist in 
the opposite direction from that of the spine. This results in a 
change in its horizontal diagonal diameters, by which the one from 
the side of the convexity behind, to the concavity in front is length- 
ened, and the corresponding one on the other side is shortened. For 
example, in right dorsal scoliosis the thorax is displaced to the right 



THORAX 



91 



and becomes prominent on the right side behind and the left side in 
front, and the diagonal diameter from the right side behind to the 
left side in front is lengthened. As a result of this the internal sur- 
faces of the shafts of the right ribs are brought nearer to the front of 
the vertebral bodies, and the right side of the thorax is seriously 
diminishedin capacity. 




Fig. 70. — Radiogram of Left Scoliosis, Resulting from Empyema of the Right Side 
WITH Resection of the Ribs. 



Ribs. — The ribs on the convex side of the lateral curve show a 
backward increase of their angularity, forming on the side of the 
back of the thorax a more or less sharp and prominent ridge, spoken 
of technically as ''the rotation" (Rippenbuckel). In compound 
curves of the dorsal region these phenomena accompany each curve. 
From the angle forward to the sternum the ribs of the convex side 
show a loss of their normal curve. 



92 



PATHOLOGY 



The ribs on the side of the concavity of the laterial curve show a 
straightening of their angles and an increased outward bowing of 
their shafts. The costal cartilages of the concave side in front show 
an increased curvature forward and form on the front of the chest a 
prominence at the side of the sternum (vordere Rippenbuckle). 




Fig. 7 1. — Thoracic Ring in a Right Dorsal Scoliosis, seen from Above. — (Lorer.z.) 



The ribs of the side of the convexity are spread apart and have 
a more oblique direction ; on the side of the concavity they are closer 
together and tend to a more horizontal course. These phenomena 
are dependent upon the degree of inchnation of the part of the spine 
to whix:h the ribs are attached. 

Sternum. — The sternum as a rule deviates but little from its nor- 
mal position and direction except in very severe scoliosis. The 
variations in position consist — (i) In a lateral displacement; (2) in 
an obliquity of the lower end, which turns either to the convexity or 
concavity of the lateral curve; (3) in a rotation around its longitudi- 
nal axis, making one lateral border, commonly the one toward the 
concavity of the lateral curve, more prominent. A detailed study 
of the variations of the sternum may be found in the reference.^ 

1 Fauconnet "Zeitsch. f. orth. Chir.," xvii,page 20 i. - 



PELVIS 93 

SHOULDER-GIRDLE 

The marked deformity of the thorax cannot be without influence on 
the form of the clavicles and scapulae. The scapula undergoes, be- 
cause of the deformity, various changes of position and eventually of 
form. It always acquires that position to which it is forced by the 
form of the thorax, the weight of the shoulder and arm, and the ten- 
sion of its muscles. On account of the backward prominence of the 
thorax, the scapula is moved away from the vertebral column on the 
convex side, and if the scoliosis is located high up in the dorsal region, 
the scapula moves upward also. If the thorax is strongly compressed 
from the side, the scapula may lie sidewise, so that its dorsal surface 
-has a lateral and not a backward direction, or it may swing backward 
so that its inferior angle crosses the line of spinous processes to the 
other side. It may furthermore acquire a strong curve on itself if 
it Hes on a thorax sharply deformed, and becomes convex backward. 

The clavicle, whose first function is to keep the scapula at a certain 
distance from the sternum, also changes according to the situa- 
tion of the spinal curve, and may be found more sharply curved in 
scoliosis. 

PELVIS 

Sacrum. — In low curves (generally convex to the left in the lumbar 
region) the sacrolumbar junction becomes practically the apex point, 
and here one looks for rotation, and pressure changes. The sacrum 
is affected in such low lateral curves in a way analogous to that of the 
other vertebrae, but' modified in extent by its fixed position. In a 
right dorsolumbar curve the following changes in the sacrum were 
found and may be taken as exemplifying them (Schulthess) : 

1. A decrease in the height of the first sacral vertebra on the con- 
cave side (c/. wedge vertebra). 

2. A broadening of the base of the sacrum on its concave side (r/. 
broadening of concave side of vertebral body). 

3. Forward displacement of the left or concave half with its cor- 
responding ala and backward displacement of the right or convex 
half (c/. rotation of vertebral bodies). 

4. Broadening of the part of the sacrum corresponding to the 
pedicle on the concave side. 

5. Lowering of the arch on the concave side. 

In addition to this there is to be seen at times a slight indication 
of a lateral curve of the sacrum, reaching its apex at or below the 



94 



PATHOLOGY 



middle of the bone. In this the coccyx may share, emphasizing the 
curve, but the sacral curve is most easily seen by sighting along the 

anterior surface of the sacrum 
or looking down the vertebral 
canal. This curve shows sHght 
indications of the same changes 
noted in the presacral vertebrae. 
The pelvis is somewhat 
changed in diameter and shape 
in severe low lumbar curves in 
which the sacrum shows distor- 
tion. In a left lumbar curve 
the diagonal diameter from the 
left side behind to the right 
side in front is greater than the 
opposite diagonal; thus, in an 
individual case of right dorsal 
left lumbar curve the thorax 

Fig. 72.— Oblique Pelvis Accompan^-ixg and pelvis WOuld be twisted in 
Scoliosis. — (Warren Museum, cast from a •^. Ji- ^.• 

specimen in ilusce Dupuytten, Paris.) OppOSlte QireCtlOnS. 




SKULL 

In long-continued scohosis, especially of the upper part of the 
column, asvmmetrv of the face and skuU mav exist. 



IXTERX-\L ORGANS 

In scoliosis, especially in moderate and severe forms, a shortening 
of the trunk is apparent which prevents the normal development and 
function of the internal organs. By the lateral displacement of the 
trunk and rotation of the thorax the pleural and abdominal ca\4ties 
become distorted. The patients become anemic and show a certain 
disposition to tuberculous pulmonary' diseases. Bachmann/ in 197 
autopsies in scoHotic patients of moderate and severe type has found 
in 28.3 per cent, tuberculous disease of the lungs, while in milder de- 
grees of scoliosis there were 66 per cent, so affected. 

The secondary changes in the internal organs are essentially de- 
pendent upon the narro\sing of the containing ca\ities. In a severe 
right dorsal cur\'e the right pleural ca\ity is very much narrowed — so 
much so that in extreme cases the iimer surfaces of the ribs are found 
lying close to the vertebral column. The narrowing of the pleural 

1 Bachmann: ''Bib. med.,'" Abt. i. Heft 4, 1899, 



INTERNAL ORGANS 95 

cavity on the left, that is, on the concavity, is not so important as 
that of the right. It follows that the right lung must suffer from the 
distortion more than the left. Mosse^ found apex infiltration in 60.2 
per cent, of 100 scoliotic children between five and sixteen years old. 
Kamine v. Zade^ found apex affections in 73 per cent, of scoliotic 
women, the lung affection being predominantly of the lung on the 
convex side of the curve. 

Affections of the pleura, adhesive pleuritis, leading to total oblit- 
eration of the pleura and atelectasis, are found very frequently. 

Undoubtedly the lungs of scoliotic patients, especially in cases of 
kyphoscoliosis, are predisposed toward a greater number of diseases 
than the lungs of normal individuals. 

Heart and Vessels. — The same narrowing of thoracic space affects 
the heart. It is frequently found pushed upward and pressed 
against the anterior chest-wall, and it is at the same time, according 
to the direction and the extent of the curvature, more or less dis- 
placed laterally. In right curves generally, the heart is displaced 
toward the left; but this is not a constant condition. Hypertrophy 
and dilatation of the cavities of the heart are very frequent, espe- 
cially of the right heart in severe scoliosis. Bachmann found it in 

56.4 per cent, of cases, while the left heart was similarly affected in 

17.5 per cent. This phenomenon was found in both right and left 
sides in 25.9 per cent. 

The aorta in general, follows the curvature of the spine, particu- 
larly in right curves. In a left dorsal curve, however, the aorta does 
not, as a rule, lie on the convex side of the curve, but runs straight 
like the chord of an arc, more often in front or even a very little to the 
right of the spine. The large veins show less typical changes. The 
vena cava in the region of the liver, where it is relatively fixed, and 
occasionally at the entrance of the renal veins, may show a change in 
its course corresponding to the change of position of the organs. 

The most reasonable explanation for the hypertrophy of the heart 
is the insufficient depth of respiration of scoliotic patients. Even in 
relatively slight distortion of the thorax, respiration is more shallow 
than the normal, consequently the right side of the heart, in order to 
push the necessary amount of blood through the lungs, must do an 
extra amount of work. 

If the scoliosis increases, the chest space is restricted still more, and 
the expansion of the lungs, already damaged by adhesions and thick- 

1 Mosse: "Zeitsch. f. klin. Med.," xli, pages 1-4. 

2 Kamine v. Zade: "Deut. Arzte. Zeit.," 1902, xx. 



96 PATHOLOGY 

ening, is impeded. The heart is also pressed against the front wall of 
the chest, and the blood-presssure is changed on account of the bends 
in the vessels, which conditions add greatly to the work of the heart. 
The difficulty which the blood finds in passing through the lungs leads 
to a great degree of venous dilatation if the condition continues long 
enough. This is especially noticeable in the veins of the head, neck, 
and arms. 

Esophagus. — In general the esophagus has a tendency to deviate 
in the direction of the concavity of the curve, although frequently its 
form and course are but little changed. The influence upon the 
course of the esophagus is least when the radius of the curve is a large 
one and the secondary curve lies below the diaphragm. In every 
case the esophagus follows a straighter course than the aorta, and it 
crosses the aorta near the point at which it pierces the diaphragm.^ 

Intestines. — The abdominal contents are, in consequence of re- 
stricted space, pressed downward and forward, and added to this is 
the influence of the approximation of the chest to the pelvis and the 
side displacement of the vertebral column. The downward pressure 
results in crowding the intestines into the true pelvis. The lateral 
displacement of the thorax ajEfects chiefly the transverse colon, which 
may become almost vertical. 

Liver. — In right curves the liver is pushed toward the left, the left 
half is better developed than the right half, and finally the organ on 
the right side may be indented by the ribs. 

Kidneys. — In right dorsal scoliosis the right kidney is often dis- 
placed upward along the spine and the left one downward, and while 
the right kidney suffers as a rule slight changes, the left is more likely 
to be affected severely from rib pressure. Cystic degeneration and 
floating kidney are common. Bachmann enumerates, among 180 
observations, 14 cystic kidneys, 31 cases of granular atrophy, 18 
cases of simple atrophy, and 6 cases of hydronephrosis. 

Spleen. — The spleen may be higher than normal. Perisplenitis, 
atrophy, and cyanotic induration have been observed (Bachmann). 

Stomach. — The position of this is influenced by that of the liver 
and duodenum. , The pylorus is depressed, while the cardiac end 
generally lies high. 

1 Hacker: "Wien. med. Woch.," 1887, page 46. 



CHAPTER VIII 
ETIOLOGY 

The subject of the etiology of scoHosis easily lends itself to elabora- 
tion and in discussing it there is difficulty in preserving simplicity. 
It will clear matters very much to remember that there are two types 
of scohosis, one the postural, better spoken of sls false scoliosis which 
is really only faulty attitude and has its own causes, and second, the 
structural or true scoliosis where there is pathological change in the 
vertebrae, and where a different set of causes must be looked into. 
That false scoliosis passes into true scoliosis at times has been already 
mentioned, but not all true scoliosis originates in false scoliosis. 

In real scoliosis there are met many cases so severe that they can- 
not be accounted for by the assumption that they are the natural 
result of the maintenance of a growing, normal spinal column in a 
malposition over a period of years, and one must look for an addi- 
tional cause. These causes are as a rule to be found in (a) congenital 
anomalies of the spine and its appendages; (b) rickets; (c) empyema; 
(d) infantile paralysis, and (e) cases where the deformity of the bones 
is so great that one must assume the existence of a diminished indi- 
vidual resistance of bone. In the last class of cases many writers 
would assume in all instances the existence of rickets as explaining 
the softness of the bones, but as in many of the cases evidences of 
rickets are not to be found, it seems fairer to meet the situation by 
the statement that there is apparently a diminished resistance of 
bones in such cases of unknown origin, but that no demonstrable 
evidence of rickets is present. 

As a practical application of the foregoing one may assume that a 
short leg, e.f^., will cause asymmetry and faulty attitude, i.e., false 
scoHosis, and in certain cases may be apparently accountable for mild 
degrees of real scoliosis, but that it is not competent to cause a mod- 
erate or severe scoliosis in a child whose bones possess a normal resist- 
ance to pressure, but if the bones do not possess this resistance 
because of rickets or for causes that we do not at present recognize, 
that it or any similar cause may result in moderate or severe scoHosis. 

97 



go - ETIOLOGY 

The following conventional schematic representation of the causes 
of scoliosis is to be interpreted in the light of what has just been 
said. 

A. Congenital scoliosis. 

1. Malformation of the spine. 

2. Malformation of the scapula. 

3. Malformation of the thorax. 

4. Deforming intrauterine pressure. 

5. Paralysis of intrauterine origin. 

B. Acquired scoliosis. 

1. Anatomical, physiological, or other asymmetries elsewhere 
than in the spine. 

(a) Torticollis (wry-neck). 

(b) Pelvic asymmetry. 

(c) Pelvic obliquity (short leg) . 

(d) Unequal vision. 

(e) Unequal hearing. 

2. Pathological affections of the vertebrae. 

(a) Rickets. 

(b) Osteomalacia. 

(c) Pott's disease. 

(d) Dislocation. 

(e) Arthritis deformans. 
(/) Tumors, etc. 

3. Pathological affections of the bones and joints of the ex- 
tremities, causing asymmetrical position. 

(a) Diseases of bones and joints of the leg. 
{b) Diseases of bones and joints of the arm. 

4. Distorting conditions due to disease of the soft parts. 

(a) Infantile paralysis. 

(b) Spastic paralysis. 

(c) Nervous diseases (hemiplegia, syringomyelia, etc.). 

(d) Empyema. 

(e) Organic heart disease. 
(0 Scars. 

(g) Throat, abdominal or pulmonary disease. 
(h) Acute or chronic inflammation of the spinal muscles 
(lumbago, etc.). 

5. Habit or occupation. 



SCOLIOSIS OF CONGENITAL ORIGIN 99 

A. SCOLIOSIS OF CONGENITAL ORIGIN 

The tendency of the last few years has been very strongly toward 
the recognition of the congenital type of scoliosis. In former years 
practically all cases were regarded as acquired and the congenital 
form considered as a great rarity, but this condition is coming to be 
recognized as by no means infrequent, and every year an increasing 
number of the moderate and severe types are being transferred from 
the acquired to the congenital class. This is due largely to the devel- 
opment of the ^-ray and the study of the living spine thus made 
possible. 

In certain congenital cases of marked scoliosis where a careful 
study of the spine is possible, no congenital anomaly is to be found 
and intrauterine pressure as formulated by Hoffa^ is the presumable 
cause. Intrauterine paralysis is suggested as a cause by a case of 
Hirschberger.2 

In the majority of cases congenital scoliosis is due to defective 
formation of the vertebrae or adnexa. The period at which these 
defects originate is discussed by Kirmisson,^ Mouchet,^ and Seibert,^ 
the rib defects being secondary according to the view of the former. 

I. DUE TO MALFORMATIONS OF THE VERTEBRAL COLUMN 

Scoliosis may occur as a congenital condition in connection with 
severe malformations, such as rachischisis and the like.^ It occurs 
also as the result of less severe spinal defects, such as cervical ribs, 
spina bifida, and abnormal formation of the last lumbar vertebra. 

Congenital scoliosis may be evident — (i) immediately after birth, 
as in the case of the severest malformations (Collville^ in 1015 cases 
of new-born children found one case of scoliosis); or (2) only when 
the child begins to walk, in the case of malformations not severe 
enough to cause a curve in the recumbent position. In these latter 
cases the curvature appears as the result of the superincumbent 
weight coming upon the defective spine or as the result of asym- 

1 "Lehrbuch der orth. Chir.," 1894. 

2 "Ztsch. f. orth. Chir.," vii, i. 

3 "Revue d'Orth.," 1910, 21. 

* "Revue d'Orth.," 1910, No. 4. 

^ "Ztsch. f. o. Chir.," 191 1, xxviii, 415. 

6 Schmidt: "Allg. Path, und path. Anat. d. Wirbelsaule," Lubersch's "Ergeb. 
zur allg. Path.," 4, Jahrg., 1897. 

7 Colville: "Rev. d. Orth.," 1896, 7. 



lOO 



ETIOLOGY 



metrical growth due to the malformation. Such cases as these are 
perhaps not strictly congenital, but might be better spoken of as 
scoliosis due to a congenital cause. 

Another common location of congenital defects is in the cervico- 
dorsal region (Fig. 53). The formation of a cervical rib is often 

associated with a splitting 
of the vertebral bodies, as 
shown by the ::k;-ray, and in 
some cases the cervical rib 
is accompanied by a rudi- 
mentary extra vertebral 
body.^ The shoulder on the 
side of the cervical rib is 
elevated, and the curve is a 
sharp cervicodorsal one with 
a compensatory opposite 
curve below. Cervical ribs 
may or may not be accom- 
panied by scoliosis. In 
thirty-five preparations and 
eleven cHnical cases with 
cervical ribs Eckstein^ twice 
found scoliosis. 

At the lumbo-sacral junc- 
tion anomalies are frequent.^ 
Waldeyer found that the 
first sacral vertebra pos- 
sessed lumbar characteristics 
in thirty-three out of 265 
cases, and in eighty-three 
cases of Adolphi (48 men 
and 35 women) the twenty-fifth vertebra was the last pure 
lumbar in 3.6 per cent., the twenty-fourth in 92.8per cent., and 
the twenty- third in 3.6 per cent. AbnormaHties of the sacral 
vertebrae are discussed by Breuss and Kolisko.^ 

Sacralization of the fifth lumbar vertebra, especially if unilateral, is a 

1 Drehmann: "Verhdl. d. Deutsch. Gesell. f. orth. Chir.," 5th Congress, 1906, 
page 12. 

2 "Zeitsch. f. orth. Chir.," 1908, xx, 177. 

3 Cramer: "Verhdlungen d. Deutsch. Ges. f. orth. Chir.," 1908, 68. 
^ " Pathologische Beckenformen." 




Fig. 73- — Scoliosis Due to Congenital 
Defects in Spine and Thorax, the Ribs being 
Bifurcated and DEFECTrvE. 



MALFORMATION OF THE SCAPULA AND THORAX 



lOI 



competent cause of scoliosis.^ Numerical variation of the vertebrae, 
especially if unilateral as pointed out by Bohm,^ is a competent cause 
of scoliosis; but, as shown by Adams, numerical variation is npt as a 
rule accompanied by scoliosis because in the Dwight collection of 
sixty-four spines in the Warren Museum of the Harvard Medical 
school, all showing numerical variation, there were only seven which 
could possibly be classed as scoliotic.^ 

Melting together of vertebral 
bodies and the absence of part - ^ 

of a vertebra are the chief 
remaining causes of congenital 
scoliosis so far formulated. 

2. MALFORMATIONS OF THE 

SCAPULA 

Congenital elevation of the 
scapula (Sprengel's deformity) 
will cause a scoliosis which is 
usually a high cervicodorsal 
curve with compensating dorso- 
lumbar curve. One scapula is 
occasionally absent or 
malformed (Fig. 74). 

3. MALFORMATION OF THE 

THORAX 

Occasionally great irregular- 
ity characterizes the ribs of one 
or both sides. Some may be 
bifurcated, others are united 
by a bridge of bone, while in others certain ribs are missing. Such 
irregularities are a cause of scoliosis. 

Heredity must also be considered, as it is known that scoliosis is 
apparently inherited in some families, Schulthess estimating that 
from 10 to 15 per cent, of scolioses are hereditary. Congenital 
defects of form can be inherited, and would reasonably lead to similar 
forms of scoHosis, while an inherited weak skeleton or a disposition to 

1 Adams: "Am. Journ. of Orth. Surg.," July, 1914. 

2 "Boston Med. and Surg. Jour.," Nov. 22, 1908; "Berl. klin., Wchsft.," loio, 
2; "Berliner Klinik," Feb., 1910. 

^"Boston Med. and Surg. Jour.," Apr. 28, 1910. — ^ 




Fig. 74- — Congenital Elevation of the 
Scapula Causing Scoliosis. 



I02 ETIOLOGY 

rickets would not necessarily lead to a reproduction of the form of 
scoliosis. There are cases, however, in which the form also seems to 
be hereditary. 

B. ACQUIRED SCOLIOSIS 

Scoliosis is to be classed as acquired when the deformity comes on 
after birth from some cause not apparently congenital, and this 
includes, so far as we know now, the greater number of cases. The 
experimental production of scoliosis in animals has been demon- 
strated and is discussed elsewhere (page 48) . The acquired varieties 
of scoliosis may be considered as follows: 

I. ANATOMICAL OR PHYSIOLOGICAL ASYMMETRIES ELSEWHERE 
THAN IN THE SPINE 

{a) Torticollis, — or wry-neck, a condition characterized by the con- 
traction of one sternocleidomastoid muscle, causes a tilted and 
twisted position of the head and necessitates a compensatory lateral 
curve of the spine to preserve the balance and enable the head to 
assume a more normal position. Unilateral torticollis, if sufficiently 
long continued, is always accompanied by scoliosis. 

{b) Asymmetry of the Pelvis. — The spine is not always located in 
the middle of the pelvis, but at times is found at one side of the 
median sagittal plane of the body (amesiality of the pelvis). The 
pelvis may be in other respects asymmetrical. In these cases a 
compensating lateral curve is necessary in order to allow the head 
to be held over the center of the body^ (Fig. 75). 

Hasse^ held that he had rarely seen a symmetrical pelvis, and 
Naegele in a collection of fifty pelves, could not find one to show to 
his students as normal. 

(c) Obliquity of the Pelvis. — ^Any condition which causes the 
pelvis to be held higher on one side in the horizontal plane is a com- 
petent cause of scoliosis, because such obliquity necessitates a lateral 
curve of the spine to secure normal balance. A short leg must 
therefore be counted as a possible cause of scoliosis. But it must be 
remembered that a difference in the length of the legs is very common 
in children,^ and that the frequency of permanent scoliosis is much 

1 "Arch f. Anat. and Phys.," 1801. 

^ "Das Schrag. verengte Becken.," 1839. 

3 Bradford and Lovett: "Orth. Surgery," 3d ed., page 476. 



SCOLIOSIS CAUSED BY ASYMMETRY 



103 



less than the frequency of short legs (Fig. 76). The association of 
short legs and scoliosis has been investigated, with varying results; 
and Schulthess estimated, without analyzing his cases, that from i to 
5 per cent, show this association. The measurement taken with a 
tape-measure from the two anterior superior spines to the inner 

malleoli while the patient 
lies on the back is inexact 
and of little value as deter- 
mining the real position of 
the pelvis in standing, and 
much importance must not 





Fig. 75. — Scoliosis Due to Asymmetry of the 
Pelvis, the Right Side Being Smaller. 



Fig. 76.^ — Left Lumbar Scoliosis Associated 
WITH Inequality in the Length of Legs. 



be attached to it. The most reliable method that we have of 
determining the horizontal plane of the pelvis and the obliquity 
which must exist when there is really a short leg is to make level 
the two anterior superior spines when the patient stands erect by 
means of pieces of thin board placed under one foot, but even this 
is inaccurate on account of the frequency of asymmetry of the pelvis 
just alluded to. It is an occasional experience to find that the 



Scoliotic, 
Per Cent. 


Myopic, 
Per Cent. 


8.7 


3-0 


18.2 


4 


5 


19.8 


5 


2 


.27.2 


6 





28.3 


8 


5 


32.4 


13 


7 


31.0 


19 


4 



104 ETIOLOGY 

spinal curve is increased by putting a block under the foot on the 
side shown to be short by measurement, and that the spinal curve 
is thus improved by making the long leg longer. 

{d) Unequal hearing causes a tilting or twisting of the head which 
may produce a temporary lateral curve in the cervical and upper 
dorsal regions. 

{e) Unequal vision, necessitating a tilting of the head to bring 
vertical objects into clearer vision, may cause a lateral curve. The 
school observations at Lausanne are of interest in this connection, as 
a steady increase in the percentage* of scoliotic and myopic children 
was found from the lowest classes upward, as is shown by the table. 

Class 

I 

II 

Ill 

IV 

V 

VI . 

VII 

The relation between scoliosis and myopia has not yet been 
determined. 

It is obvious that astigmatism may be a cause of head tilting. The 
subject has been carefully worked out by Gould, ^ whose conclusion 
is that in asymmetrical astigmatism the axis of the dominant eye 
determines a tilting of the head to the right or left, but that this 
does not occur in symmetrical astigmatism. 

But it must be remembered that those conditions which cause the 
spine to be held asymmetrically, and which have just been men- 
tioned, are frequent, while structural scoliosis is not by any means so 
frequent. And one must assume that in those cases where severe 
or moderate structural changes have occurred as a result of this 
asymmetrical position that the bones of the individual possess less 
than normal resistance. 

2. PATHOLOGIC./y. AFFECTIONS OF THE VERTEBRA 
(a) Rickets, 2 which is a constitutional disease beginning in the 

1 G. M. Gould: "Amer. Medicine," May 21, 1904; Mar. 26, 1904; April 8, 
1905; "N. Y. Med. Record," Apr. 22, 1895. H. A. Wilson: ''N. Y. Med. 
Journal," June, 1906. 

^Kirsch: "Verhdlg. d. Deuts. Ges. f. orth. Chir.," 1910, page 94; Bohm: 
"Verhdlg. d. Deuts. Ges. f. orth. Chir.," 1910, page 49. 



PATHOLOGICAL AFFECTIONS OF THE VERTEBRA 105 

first dentition which leads to a softening of the bones, has long been 
recognized as a cause of scoliosis. But the trend of recent opinion is 
toward assigning rickets as a cause of scoliosis in a very much larger 
number of cases than was formerly done. Indeed, some writers 




Fig. 77. — Scoliosis and Osteomalacia Showing Compression and Distortion of 

VERTEBRiE. 

would go SO far as to assume that practically all organic scoliosis, not 
obviously due to a congenital defect or some such obvious cause as 
empyema or paralysis, is due to rickets. The situation in this 
regard has been already discussed at the opening of the chapter. 
The typical rachitic variety of scoliosis is characterized by a sharp 



io6 



ETIOLOGY 



and severe curve oftenest in the lower spine, with shortening of the 
trunk. It is one of the "most resistant forms to treatment and is a 
variety which begins early as the softness of the bones is most marked 
during the acute process. The recognition is made by the presence 
of the other signs of rickets found in the deformed bones elsewhere 
and by the usual diagnostic signs. 

(b) Osteomalacia, an uncommon process, like rickets in causing a 
softening of the bones, but more frequently seen in adolescents and 
adults than in children, is accompanied occasionally by lateral 
curvature. 

(c) Tuberculous disease of the spine, or Pott's disease, is a 
destructive pathological process attacking the bodies of the vertebrae. 

Lateral deviation of the 
spine associated with stiff- 
ness often exists in connec- 
tion with the backward 
"hump" or kyphosis, which 
is the characteristic sign of 
the disease. This early 
form is generally atypical, 
with little rotation. In the 
early stages of Pott's disease, 
lateral deviation is present 
as a symptom of irritation. 
In the later stages of Pott's 
disease lateral asymmetry 
may be present as the result 
of unilateral destruction of 
one or more of the diseased 
vertebrae. 

(d) Severe injuries of the spine, resulting in chronic sprain of the 
vertebral column, dislocation of the vertebrae, fracture of the verte- 
bral bodies, and injury of the epiphyseal cartilage, may be accom- 
panied by lateral deviation of the spine as a symptom. 

{e) Arthritis deformans is characterized by a progressive stiffening 
of the spine due to deposits of newly formed bone on the front and 
sides of the column, binding the vertebrae together. The interver- 
tebral discs degenerate and the vertebrae become fused; bony deposit 
occurs in the ligaments, and the articulations of the vertebrae with 
the ribs may lose some or all motion. Lateral deviation, accompa- 
nied by general kyphosis, is generally present, but is atypical and 




Fig. 78. — Severe Scoliosis Due to Rickets. 



PARALYTIC SCOLIOSIS I07 

accompanied by little rotation (see Ischias Scoliotica, page 109). 

Other causes of this class are tumors of the spine and, it is said, 
hereditary syphilis. 

The scolioses of this class are symptomatic of a serious condition, 
and except for that of rickets, are not to be treated like ordinary pri- 
mary scolioses but would be injujed by such treatment. 

3. AFFECTIONS OF THE BONES AND JOINTS OF THE EXTREMITIES 

(a) Diseases of the bones and joints of the lower extremity 

play a larger part in the etiology of scoHosis than those of the arm 
and shoulder. Lateral curvature may be caused by the shortening of 
one leg due to derangement of growth; to unilateral diseases of the 
hip- joint causing shortening, dislocation, contraction, or ankylosis in 
a position of adduction, abduction, or flexion; to unilateral congenital ' 
or paralytic dislocation of the hip; to coxa vara, coxa valga, and 
fractures of the lower extremity; to diseases and malformations of 
the diaphyses of the leg or thigh bones; to diseases of and operations 
on the knee-joint causing shortening, contraction in the flexed posi- 
tion, or knock-knee on one side ; and to diseases and malpositions of 
the foot, especially flat-foot. 

(b) Diseases of the shoulder-joint, causing partial or complete 
ankylosis, may be accompanied by a curve of the spine in the 
dorsal region. 

4. DISTORTING CONDITIONS DUE TO DISEASE OF THE SOFT 

PARTS 

(a) Infantile spinal paralysis or anterior poliomyelitis is a very 
frequent cause of a severe type of lateral curvature. 

I . The deformity is most often due to a weakening or paralysis of the 
abdominal muscles on one side, or to a greater weakening on one side 
than on the other. Abdominal paralysis is exceedingly common in 
this affection and has been largely overlooked as the chief cause of 
scoliosis. 

Some degree of paralysis of the abdomen was found in 7 2 per cent . of 
1461 recent cases examined in New YorkStatein I9i6-i7,andlateral 
curvature of the spine was found in 69 recent cases in this series, and 
in no out of 375 cases affected in previous years. ^ 

With the abdominal muscles of one side unopposed it is easy to see 
how lateral deformity would result, and the existence of any degree 
of abdominal paralysis in these cases is an indication for the closest 
watchfulness of the surgeon in this respect. 

^ R. W. Lovett: "Jour. Am. Med. Assn.," July 21, 1Q07. 



io8 



ETIOLOGY 



Scoliosis will in most cases appear when one arm is paralyzed, 
even with the abdomen intact. 

2. Unilateral paralysis of the muscles directly controlling the 
vertebral column may cause a deviation of the spine either to one 
side or to the other. It does not follow, as shown by Arndt exper- 
imentally and as recognized clinically by others, that a paralysis of 
the muscles of one side of the back is followed by a curve con- 
vex toward the paralyzed muscles, as would naturally be expected. 
The curve is the result of the effort of the patient to adjust his center 




Fig, 79- — Right Dorsal Left Dorso- 
LUMBAR Curve Due to Infantile 
Paralysis, 



Fig, 8o, — Severe Right Curve Due to 
Infantile Paralysis. 



of gravity to the new conditions induced by unilateral paralysis. 
This equilibration may result in a curve convex either to the right 
or left in a right sided paralysis of the abdomen. 

Shortening of one leg due to poliomyelitis may cause lateral 
curvature in the same way that any form of short leg will cause it. 

(b) Spastic paralysis or Little's disease is the result of a cerebral 
lesion and a descending degeneration of the lateral columns of the 
spinal cord. The growth of bones is often retarded, and muscular 
irritabiHty and stiffness are noted with contractions. Scoliosis is an 
occasional accompaniment. 



PARALYTIC SCOLIOSIS IO9 

(c) Other nervous diseases, represented by a much smaller num- 
ber of cases accompanying lateral curvature are multiple neuritis, 
meningitis, cerebrospinal meningitis, syringomyelia, pseudomuscular 
hypertrophy, locomotor ataxia, Friedreich's ataxia, tumors of the 
spinal cord, and obstetrical paralysis. 

A marked lateral deviation of the spine, extensively studied by the 
Germans and termed by them Ischias Scoliotica,^ is a form^ without 





Fig. 81. — Severe Right Curve (see Fig. Fig. 82. — Same Case as Figs.'tS' and 79 

78) Due to Infantile Paralysis. Showing Deformity of Lowerj Rib. 

Showing abdominal and thoracic con- Induced by Pressure. 
struction on left. 

much rotation which accompanies the inflammatory affections of the 
lumbar region vaguely classed as "lumbago" and ''sciatica." It is 
frequently found in arthritis of the spine and in acute and chronic 
sprains of the spine. 

A similar malposition is observed in hysteria^ (Fig. d>^). An 
analogous deviation is found in disease of the sacro-iliac joint in 
which the lateral curve is induced by the instinctive effort to spare 
the affected joint. 

^ Stein: "Zeitsch. f. orth. Chir.," xxv, 1910, 479 (with literature). 
^Binswanger: "Hysterical Scoliosis/' "Deutsch. mod. Wochen?.," Vereinsbeil., 
1902. 5. 



no 



ETIOLOGY 



{d) Empyema^ is followed by lateral curvature in certain cases, 
both without operation and after the operation for removal of a rib. 
The scar contraction seems to be the cause of the chief curve, which is 
always to the right in left empyema and vice versa. There are likely 
to be compensating curves above and below the main curve, the 
height of the shoulders is generally very different and the hyper- 
trophy of the sound side of the chest is a marked feature (Fig. 84). 




Fig. 83. — Hysterical Scoliosis. 



Fig. 84. — Right Dorsal Curve Due 
TO Left Empyema. 



{e) Scars rarely cause scoUosis, although it sometimes is found 
after extensive unilateral burns when the deviation of the spine is 
brought about by contraction of the scar tissue (Fig. 85). 

(/) Phthisis and diseases of the pleura and obstructions in the 
nasopharynx are to be mentioned among the diseases of the respira- 
tory organs sometimes followed by scoliosis. 

{g) Organic heart disease, especially in children, is a competent 
cause of lateral curvature (Fig. 86). 

-Walther: "Zeitsch f. orth. Chir.," 1910, xxv, 401. 
Gaugele ^Munch. IMed. Wcksft.. 191 9, xvi. 



OCCUPATIONAL SCOLIOSIS 



III 



5. HABIT OR OCCUPATION 

That the continued maintenance of an asymmetrical portion of the 
spine through the period of growth may result in some degree of 
bony deformity of the growing spine is a self-evident proposition, 
dependent on the fact that growing bone is plastic and follows the 
line of least resistance. But that such conditions are likely to result 
in moderate or severe scoliosis in normal children is not, in the 
opinion of the writer, likely. That they may result in ''false scohosis" 
or slight true scoliosis is apparently reasonable to expect. 




Fig. 85. — Scoliosis Due to Extensive 
Burn of Left Chest Received at the Age 
of 17. Patient now 19 Years Old. 



Fig. 86. — Severe Scoliosis Associated 
vi^iTH Organic Heart Disease. Death 
Occurred from the Latter. 



The commonest causes of "occupation" scoliosis are to be found 
in children in the assumption of faulty attitudes at school and at 
home, violin playing, the use of a side saddle in horseback riding, 
carrying heavy weights asymmetrically, etc. 

The relation of scoliosis to school life has been much discussed and 
will be considered by itself. 



CHAPTER IX 
OCCURRENCE 

Scoliosis in Quadrupeds. ^ — Socliosis in animals other than man 
has been observed, but is rare. Eighteen cases were found in Utera- 
ture by Hartel in 1909. Ten of these were foetal malformations 
found in new-born horses, goats, deer, and calves; curves due to 
rickets were found in pigs, and in cattle an inflammation and growing 
together of vertebrae or parts of vertebrae. In addition may be men- 
tioned scoliosis in a colt one and one-half years old and in a goat, and 
a case of scoliosis due to congenital defect of the vertebrae in the 
cervical region in a horse. 

Such curves in mammals consist of short sharp curves accompanied 
by torsion, but what corresponds to real '^ habitual scoliosis" in 
the human being has not been definitely established as existing in 
quadrupeds; a real static deformity, however, is the sway back ob- 
served in horses.^ 

In the lower vertebrates scoliosis has been observed in fishes, 
snakes, and eels. Among domestic fowls scoliosis is not uncommon 
in hens, ducks and geese, and Klapp and Hartel collected a dozen 
scoliotic skeletons from this source in one year. The study of this 
deformity in fowls has a certain bearing on scoliosis in man because 
of the fact that in birds the weight is borne on two limbs, although 
the position of the spine is much more horizontal. In quadrupeds 
the horizontal position of the spine and its support on four limbs 
makes the static relations wholly different from those existing in man. 

In fowls the examinations of Hartel show two distinct classes of 
cases; first, an atypical scoliosis due to vertebral defects and uni- 
lateral numerical variation of the vertebrae, an important matter as 
bearing on the similar condition in man; and, second, a typical 
scoliosis accompanied by rotation of the vertebral bodies to the con- 
vex side of the curve, which is more frequent than the first-named 
variety. As bearing on the etiology of the latter, changes attribu- 
table to trauma, inflammatory processes, and rickets were absent 

1 Hartel: "Deutsch. Ztschft. f. Chir.," 98, 277. 

^Rievel: " Knockenpathologie der Tiere." "Lubarschs and Ostertags Erge- 
buisse," xi, 1907. 

112 



FREQUENCY II3 

in the ten specimens examined, and in such we must attribute the 
cause either to intra-uterine pressure or to purely static causes arising 
late in life. That is to say, we must assume that the bones of the 
individual fowl possessed less than normal strength and yielded 
under weight. 

In quadrupeds, therefore, one finds as causes vertebral anomalies, 
inflammation of bones, and rickets. In fishes and snakes apparently 
the first named of these three causes, and in fowls vertebral anoma- 
lies alone, can be demonstrated as causes, leaving the bulk of the 
cases (ten out of twelve) to be accounted for as deformities due to 
weight acting on bones of less than normal resistance. Experiment- 
ally scoliosis has been produced in animals by Wullstein, Arndt, and 
Ribbert. 



FREQUENCY . 

Figures with regard to the frequency of scoliosis in the population 
as a whole are lacking, except for some figures brought forward by 
Schanz.^ In five years, of 189,000 recruits available, for the German 
army 7.2 per thousand were disqualified for spinal curves of all kinds; 
that is, less than i per cent. Figures with regard to the percentage 
of scoliotics in hospital practice show nothing because the clientele of 
various hospitals varies so largely. Fortunately there are figures 
relating to its frequency in school children which are available, which 
form our only reliable means of judging its frequency. 

It is evident, however, that the percentage of scoliotics among a 
number of school children examined will vary with the point of view 
and standard of the observer, and this is shown by the very great dis- 
crepancy shown in the tables commonly quoted. These as a rule 
include old and new figures from all over the world from observers of 
every degree of special qualifications. Such a table is given (Table V) . 

The very careful and modern investigations of Combe, Scholder 
and Weith, Gronberg,^ Haglund,^ and Lubinus"^ seem to form the 
safest basis for conclusions. -According to these, the frequency in 
girls of the school age varies from 10 to 23 per cent, and of boys from 
16.4 to 26 per cent. 

1 "Verhdl. d. Deutsch. Ges. f. orth. Chir.," 1910, page 454. 
2"Ztsch. f. orth. Chir.," xviii, 130. 

3 "Ztsch. f. orth. Chir.," xxv, 649. 

4 "Verhdl. d. Deutsch. Geo. f. orth. Chir.," 1910, 469. 



114 



OCCURRENCE 



It has been noted, however, that the percentage varies in different 
locaUties without obvious reasons, Grongerg finding in Abo a percent- 
age of 1 1.6, while in the neighboring Finnish city of Wilborg similar 



Table V 





Place 


Boys 


Girls 


Observer 


No. 


Scoliosis, 
per cent. 


No. 


Scoliosis, 
per cent. 


1864 Guillaune 

1892 Bardenheur and 
Castenholz 

1893 Brunner, Klaus- 
ner and Seydel 

1894 Krug 

? Hagmann 

? KaUbach 

1901 Combe, Scholder 
and Weithi 

1906 Silfwerskiold 

1907 Gronberg 

2 1910 Haglund 

1910 Lubinus 

3 1913 Briining 

^ 1920 Schlesinger 


Merchatel 
Cologne 

Munich 

Dresden 
Moscow 
St. Petersburg 

Lausanne 

Goteborg 

Wiborg 

Stockholm 

Kiel 

Oberhesser 


350 

1,052 
569 
695 

1,290 


4,257 
819 

1,021 

6,816 
12,860 


18 

6.2 

8.5 
26 

23 

II. 9 
13.2 
10 
12 


381 
439 

987 

489 

723 

1,664 

2,333 

1,024 
3,234 
4,093 
780 
2,204 
5,404 


41 
23 

8.2 

6.5 
22.5 
29 
26 

26.7 

12.8 

22. 1 

16.4 

18 

10 

12.5 
(both ■ 
boys and 
girls) 







1 Jabrh. d. Schweitz. Ges. fur Schulges. pflg. 

2 "Ztsch. f. orth. Chir., 1913, xxxiii, 518. 
^Ztsch. f. orth. Chir., 1910, xxv, 649 

4 Arch. f. Klide, 1920, 68, 289. 



1901; Jahrg. z. Teil I, p. 38. 



investigations by Gronberg showed 34.5 per cent, of scoliosis, and 
Lubinus found in Kiel in different girls' schools of the same grade that 
the percentage of scoliotics varied from 13. i to 34.6 per cent, without 
assignable cause. This has nothing to do with the variation accord- 
ing to age to be discussed later. 

SEX 

It is generally the opinion that in adults women show a greater 
number of scolioses than men, although pubHshed statistics confirm- 



AGE 115 

ing this fact do not exist. Records of the relative frequency of sco- 
liosis in adolescents and children made in orthopedic institutions 
where patients apply for treatment show a very much larger percent- 
age of scolioses among girls than in boys. The difference between 
the sexes is less where large numbers of school children are investi- 
gated, such figures showing in general a slightly higher percentage in 
girls than in boys. To explain this difference we must either assume 
that boys outgrow scoliosis or that they do not come to the institu- 
tions for treatment until the curves become severe or until complica- 
tions arise, while in girls the effects of scoliosis upon the figure are 
perceptible much earher, and treatment is sought to remedy curves 
which in boys would pass unnoticed by the parents. 

The table which follows shows the great preponderance of girls 
coming to institutions for treatment. The figures for the proportion 
of the sexes in school children are given in the table in the section 
on Frequency. ^ 

Figures from Institutions where Patients are Treated 

Boys, Girls, Boys, Girls, 

Per Per 

Cent. Cent. 

Eulenburg 13 87 Adams 12.8 87 

Ever 7 93 Scholder 14 . 8 85 



Per 
Cent. 


Per 
Cent. 


13 


87 


7 


93 


17 


83 


20 


80 


8.5 


91 



Ketch 17 83 Schanz 25 74-8 

Kolliker 20 80 Rosenthal 22 78 

Roth 8.5 91 Schulthess 14.2 85.5 

Wedberger 15.9 84 Redard 15.6 83.3 

Behrend 13.4 86 

AGE 

Scoliosis is an affection of the years of growth in a large majority of 
cases, but it is often extremely difficult to form an accurate idea of 
the age at which the deformity begins in individual cases. Scoliosis 
due to rickets, infantile paralysis, and congenital causes may occur up 
to the fifth year. In general, however, the inaccurate observations of 
parents furnish no foundation upon which to base theories or statis- 
tics concerning the time of the beginning of the scolioses observed in 
older children. The relation of age to scoliosis as observed in the 
schools will be discussed later. 

In regard to the age at which scoliotic children are brought for 
treatment, Eulenburg found over 50 per cent, of all cases between 
seven and ten years old, and but 10 per cent, between the ages of 
t6n and fourteen years. 



Il6 - OCCURRENCE 

The clinical material collected by the Institute of Liining and 
Schulthess at Zurich has been used by Sutter and Miiller in preparing 
curves of the frequency of scoliosis at different ages. Miiller found 
the greatest number of cases in the fourteenth year. The number 
increases gradually from the eighth to the fourteenth year, and 
decreases rapidly from the fourteenth to the seventeenth year. 
Sutter found that the number of boys brought for treatment reached 
the maximum in the ninth, thirteenth, and fourteenth years. The 
number of cases under treatment at fourteen years of age is double 
that for nine years, and shows not only an increase in frequency of 
scoliosis, but an increase of deformity in curves already existing. 

RELATIVE FREQUENCY OF THE DIFFERENT FORMS OF SCOLIOSIS 

Statements concerning the frequency of the simple forms of scoHo- 
sis are of recent origin. All statistics agree, however, in show- 
ing that for all forms there are more scolioses convex to the left than 
to the right. There is less unanimity as to which of the single forms 
is the most frequent. Lorenz states that left lumbar scohosis is the 
most numerous. KoUiker, from the examination of 721 cases, finds 
the simple dorsal scoHosis the most frequent. By considering the 
tables of other investigators Schulthess found the compound right 
dorsal scoHosis the most frequent form, followed in order by the 
simple dorsolumbar curves, total scoliosis, and lumbar scoliosis. 
The cervicodorsal form was the least frequent. 

Among the 571 school children with lateral curvature out of 2134 
children examined at Lausanne, 401, or 60.3 per cent., showed curves 
convex to the left, 121, or 21.1 per cent., curves convex to the right 
and 49, or 8.6 per cent., compound curves. The table compiled 
from these figures shows the percentages of curves as to their form 
and convexity. The total curve is the most frequent form in school 
children, and is followed by the left and right lumbar curves and by 
left dorsal scoHosis. 

Left Convex, Right Convex, Total, 

Per Cent. Per Cent. Per Cent. 

Total scoUosis 48 . i 7.8 56 

Dorsal scoliosis .... 8.4 4.3 12.7 

Lumbar scoliosis 11. 8 8.5 20.3 

Combined scoliosis 8.5 per cent. 8.5 

Almost the only records that have been studied and tabulated for 
definite study are those of the Institute of Liining and Schulthess, 



FREQUENCY OF DIFFERENT FORMS II7 

and it is from these investigations that much of the following material 
is drawn. 

Age. — At eight years the left sco hoses form 64 per cent, and the 
right scolioses 33 per cent, of the total number of curves. In the 
fourteenth year the number of curves convex to the left and right is 
about equal. The number of compensating curves increases from 27 
per cent, in the eighth year to 45 per cent, in the seventeenth year. 

Position of Apex of Deviation. — To ascertain the location of the 
point of maximum deviation Durrer has constructed a set of curves 
which show that for the left convex sco hoses the maximum deviation 
is at the dorsolumbar junction, and for the right convex curves the 
apices are found in the region of the seventh dorsal vertebra, which 
showed a much greater deviation than the adjacent vertebrae, while 
in the left convex curves the deviation is more evenly distributed 
over the length of the spine. 

Schulthess finds four principal apices of deviation for single and 
compound forms of scoliosis: (i) the upper dorsal region to the 
right; (2) the dorsolumbar junction to the left; (3) the upper dorsal 
and lower cervical regions to the left; (4) the lower lumbar region to 
the right. 

In the eighth year the maximum deviation of the right dorsal 
curves is in the region of the sixth to the eighth dorsal vertebrae, and 
is stiU found there in the seventh year. The apex of the left convex 
curves in the eighth, ninth, and tenth years is at the ninth or tenth 
dorsal vertebra; between the ages of eleven and thirteen it is found 
at the twelfth dorsal vertebra, and descends to the first or second 
lumbar vertebra between the ages of fifteen and eighteen years. 



CHAPTER X 
THE RELATION OF SCOLIOSIS TO SCHOOL LIFE 

The relation that school conditions bear to scoliosis is one of the 
most important questions in formulating the cause of scoliosis and 
has been much discussed of late. It is important to examine certain 
practical aspects of the question. 

School Fatigue. — A correct attitude is dependent upon the tone 
and strength of the muscles by which the upright posture is main- 
tained, so that any cause, such as fatigue, which lowers the muscular 
tone, has a bearing in this connection. 

Mental Fatigue. — Muscles become relaxed not alone by physical 
but by mental exertion and mental fatigue.^ Mental work is at first 
stimulating, but if continued for a long time, especially concentrated 
on one topic, will produce both mental and bodily fatigue. 

Continuous mental labor, though of only short duration, will produce a greater 
degree of fatigue, and that more quickly, than the same amount of work inter- 
rupted by brief intervals of rest. A change of work, particularly from a hard to 
an easy subject, will afford the same relief as a short rest. Severe fatigue comes 
on with great regularity in periods of the ancient languages and mathematics, 
while recuperation takes place during history, geography, and nature study. 
The modern languages occupy a middle place; singing and drawing make rather 
great demands on those who do well in these branches. After violent or pro- 
longed exercise one is less fit for study, but after moderate exercise intellectual 
work seems to become easier. The proper relation between physical and intel- 
lectual work, in order to obtain the greatest good from each, is a question which 
should receive the careful consideration of educators. 

Exhaustion in Children. — One of the first ways in which fatigue shows itself is 
in the slight amount of force expended in a movement and frequently a lessening 
in the number of movements. In extreme exhaustion the ordinary movements 
are not excited by ordinary stimuli, and such as do occur are slow and labored. 
This may be accompanied by irritability and occasional jerky movements not 
controlled by circumstances. Frequently there is manifest an asymmetry of 
posture and movement. The head is held on one side; the arms when extended 
are not horizontal — usually the left one is lower; the hand balance is weak; that is, 

iKronecker: "Ueber die Ermiidung und Erholung der gest. Muskeln," 
Leipzig, 1871; Mosso: "Fatigue," "International Science Series," Sikorsky: 
"Sur les effets de la Lassitude provoquee par les travaux intellectuels chez les 
enfants de I'age scolaire;" Leo Burgerstein: "Die Arbeitskurve einer Schul- 
stunde;" Hugo Laser: "Ueber geistige Ermiidung beim Schulunterrichte." 

118 



WRITING POSITION IIQ 

when hands and arms are held straight out in front, the fingers and wrists are not 
extended, and the thumb is not on the same plane as the fingers; this also is more 
marked in the left hand. Lack of muscular tone shows itself in a "slumped" 
position either standing or sitting. The face may be lengthened from relaxation 
of the muscles and falling of the jaw. Sighing and yawning are common symp- 
toms. Speech is slow, and the tone of the voice altered, and in general there 
are slowness and inaccuracy of mental response. ^ 

School Furniture. — It is obviously important to furnish school 
children with seats and desks which do not favor improper attitudes 
in sitting and writing. ^ In 1842 Barnard, of Hartford, published an 
article on the subject, followed twenty years later by Fahrner,^ of 
Zurich, Myer/ Cohn,^ Schenk, Lorenz,^ Schulthess,'^ and Scholdef;^ 
and a most practical study of the matter was undertaken by the 
Boston Schoolhouse Commission.^ 

The two things to be prevented in school furniture are— (a) the 
prolonged stretching of the back muscles by the continued mainte- 
nance of flexion of the spine, and (b) the assumption of distorted and 
twisted attitudes, children with tired muscles tending to rest them by 
assuming a change of position. Furniture of bad design or impro- 
perly fitted tends to favor both of these. ^^ A large number of desks 
and seats have been devised; it is said that 150 have been proposed, 
and at least over 30 have been tried. The theoretical requirements 
which are by common consent accepted are as follows: 

1 . The height of the seat from the floor should be such that in sit- 
ting the feet rest on the floor. Too high a seat produces pressure 
on the back of the thighs; too low a seat induces too much flexion of 
the lumbar spine. 

2. The slope of the seat should be backward and downward about 
three-eighths of an inch. The depth of the seat should be about two- 
thirds the length of the thighs. The width of the seat should be that 
of the buttocks. Some concaving of the seat is comfortable, but not 
essential. 

1 Warner: "The Nervous System of the Child," London, 1900. 
^Scudder: "Determination of the Muscular Strength in Growing Girls," 
"Bos. Med. and Surg. Jour.," Nov. 6, 1890. 

3 "Das Kind u. d. Schultisch," 1865. 

4 "DieMech. des Sitzens," "Virch. Arch. f. path. Anat.," xxxv, 1867. 
^ "Beitr. zur Losung der Subsellenfrage," Berlin, 1885. 
^Lorenz: "Ueber die Skol.," Wien. 

■^ Schulthess : "Zeitsch. f. orth. Chir.," 1892, i, i. 
8"Archiv fur Orth.," i, 2. 

^Boston Schoolhouse Commission Reports for 1901-5. 
loPeiss: "Cleveland Med. Jour.," Aug., 1905. 



I20 SCHOOL LIFE AND SCOLIOSIS 

3. The hack of the seat should have a slope backward of one in 
twelve from the vertical line (Saxon regulations) . The more modern 
expression of this is found in two back supports, one low do\\Ti, one- 
half to one inch in front of the back edge of the seat, and a second 
higher up, one and one-half inches behind the back edge of the seat. 
But in a nearly balanc-ed sitting position a relatively low back support 
is ample and the upper one not required. 

4. The height of the desk should be such that the back edge allows 
the forearm to rest on it naturally with the elbow^ at the side. The 
height of this edge from the edge of the seat is known technically as 
the "difference." 

5. The slope of the desk has been advocated at all angles from o to 
45 degrees. The theoretically best slope for reading is at least 30 

degrees, but this is practically 
too steep and books slide off, 
and it is not practicable for 
writing. From 10 to 15 
degrees is ■ the usually 
accepted inclination. The 
proper distance of the eyes 
from the desk is from 1 2 to 
14 inches. The width of the 
desk is immaterial, 22 to 24 
inches being the usual size. 

Writing Position. — There 
has been at times a tendency 
to blame the teaching of 

Fig. 87.— Boston School Desk and Chair.— slanted handwriting for mUch 
^Boston Schoolhouse Commission.) ^^ ^^^ ^^^ attitude and the 

teaching of vertical writing was substituted, the patient sitting 
squarely in front of the desk and writing vertically, with a view of 
avoiding the distorted position incidental to slanted handwriting. 
Statistics have been reported in favor of the vertical system. These 
are: 

Percentage of Scoliotics 
In Slanted Writing In Vertical Writing 

Nuremburg 24 15 

Zurich 32 12 

Munich 24 15 

Fiirth. 65 31 

Wurzburg 28 8 




WRITING POSITION 



121 



The question is by no means settled, Gould, of Philadelphia, having 
called attention to certain factors previously overlooked. 

" With^ the head and body erect, the paper straight before the med- 
ian line of the body, and the penholder held as commanded, no per- 
son can or will write, for the simple reason that the writing and the 
writing field about the pen-point are hidden by the writing hand and 
the penholder. Immediately the pupil skews the paper, tilts the 
head to the left, and grasps the holder differently — all in order to 
bring the writing field and letters being made into clear view, and 
especially of the right or dominant eye. 




Fig. 88. — The Hand in the Writing Posture as Usually Ordered, but not Prac- 
tised, Because to the Writer the Writing Field is Hidden by the Thumb, Finger, 
and Holder. — (Gould.) 

A view of the hand, as seen by the writer, with the head displaced in photographing. 



'' The slanted handwriting is due merely to the fact that less torsion 
or rotation of the head to the right is rendered necessary, and a slight 
easing is secured by slanting the letters to the right. 

It may be assumed as reasonable (i) that bad air, fatigue and 
school life under poor general conditions, (2) improper school furni- 
ture, and (3) twisted writing positions favor bad attitude, and that 

^ G. M. Gould: "American Medicine," i.x, 14, 562, 1905. 



122 SCHOOL LIFE AND SCOLIOSIS 

the more constantly they are in operation the more effective will be 
their result in producing bad attitude. In the same way unfavorable 
home conditions in the way of bad food, overwork, and unsanitary 
surroundings depreciate muscular strength and favor bad 
attitudes. 

It is therefore likely on general principles that unfavorable school 
conditions are a competent cause of faulty attitude (false scoliosis) 
and of sHght grades of true scoHosis, but that they are the cause of 
moderate and severe structural scoliosis is not, in the writer's opinion, 
likely. The reasons for this view have been expressed at the beginn- 
ing of the chapter on Occurrence. 

This view is in accord with that of the best modern authorities,^ 
but not in accord with former views. ^ 

It is therefore necessary to investigate existing data with regard to 
the occurrence of scoKosis in school life to see what evidence is to 
be found in them. 

There are practically no figures deahng with the question in 
America and it must be remembered that figures from foreign sources, 
although probably applying to our conditions, cannot be unreserv- 
edly accepted. It has already been shown that there maybe a great 
variation in the percentage of scoliosis in the school children of two 
neighboring cities and between children of different schools in the 
same city (see Occurrence, page 114). 

Increase of Scoliosis during School Life. — When careful statistics 
are taken among school children they show most often, but not uni- 
formly, a larger proportion of children affected with scoHosis in the 
later than in the earlier years of school. 

Haglund's studies^ were especially careful and show an increase 
with school age as follows: 

Year 6 7 8 9 10 11 12 13 14 15 1599 cases 

Per cent, scoliosis . ., 11 13 18 16 18 24 22 22 .. 283 scolioses 

Gronberg, from a careful study of 8350 school children in Finland, 
concluded that '' the frequency of scoliosis increases as age increases 
and as the classes become higher. Constancy of progression is not, 
however, always to be found." 

1 "Verhdlungen d. Deutsch. Ges. f. ortli Chir.," 1910, pages 443-514. Schult- 
hess, Schanz, Mayer, Spitzy, Bolim, Muskrat, Lubinus and others. 

'Smith: "Lat. Curv. of the Spine and Flat-foot," Xew York, 1911, page 28. 
3 "Zeitsch. f. orth. Chir.," xxvi, 649. 



CONCLUSION 123 

His tables were as follows: 

Year, 11 12 13 14 15 

Grammar schools 12.2 15.6 12.5 11. 3 16. i j 

TT- . T, , f 9-4 7-3 8.8 9.9 12.4 Boys 

Higher schools \ , . 

\ 26.1 32.7 26.9 44.4 40.3 J 

Year, 11 12 13 14 15 16 

Grammar schools .. . 21.2 18. i 19. i 23,3 26.5 21.9 ] 

TT. ■. 1 , / 16.9 18.9 21.5 20.9 22.3 24.7 \ Girls 

Higher schools {„ ^ o^Io 

[48.1 49.0 49.6 59.8 63.2 56.8 J 

The figures as to the increase of scoliosis during school Hfe from 
2314 cases examined at Lausanne are as follows:^ 

Age, Years Boys, Per Cent. Girls, Per Cent. 

8 7.8 9-7 

9 16.7 20.1 

10 18.3 21.8 

11 24.2 30.8 

12 27.1 30.2 

13 26.3 37-7 

On the other hand, certain observers have found the contrary. 
Spitzy^ for ten years has examined about 100 girls from eight to six- 
teen years old each year in a large private school for girls in Graz and 
finds a constant percentage each year of about 20 per cent, of marked 
defects of position, and this percentage is not greater in children 
who have previously been to school than in those educated at home. 
Hippius^ has demonstrated that severe scoliosis is frequent in 
children who have never been to school. 

Kirsch^ in 1000 school children from the lower classes and 1000 
from the more advanced classes investigated since 1906 found that 
"the greatest number of all fixed scoHoses, which we find in school, 
are rachitic scolioses from early childhood." 

In 3234 girls, Silfwerskiold found percentages as follows: 

Per Cent. 

First class 10. o 

Second class. 12. i 

Third class 12.5 

Fourth class 17.0 

Fifth class 9.9 

1 Combe, Scholder and Weith: "Jahrb. der Schu. Gesel. f. Schulgesundheits 
pflege," ii, Jahrg., 1901, i, Teil, 38. 

2 " Verhdl. d. Deutsch. Ges. f. orth. Chir.," 19 10, page 462. 
^ "Der kinderarzt als Erzieher," Berk, Miinchen. 

4 "Verhdl. d. Deutsch. Ges. f. orth. Chir.," 1910, 94. 



124 SCHOOL LITE AXD SC0L05IIS 

Forms of Scoliosis in School Children. — ''So far as the forms of 
scoliosis which are most frequent in children, they are in. a certain 
way peculiar and vary from the forms most frequently coming to 
specialists for treatment.'"^ 

Of these cur^^es only 24 per cent, were compound in Gronberg's 
series and the remainder were simple. 4.19 per cent, being left total 
curves.' In the Lausanne series 48.1 per cent, were left total cur^-es 
and only 8 per cent, of the whole were compound scoliosis. 

The conclusion from which, is that apparently if one takes into 
account all grades of scoHosis, functional and structural (false and 
true), there is a tendency to increase during school years, but there 
apparently is no good evidence that moderate and severe structural 
scolioses increase during school life or are directly caused by it. 

^ Gronberg: ''Zeitsch f. orth. Chir.."" xyrn., 156. 



CHAPTER XI 

DIAGNOSIS 

Scoliosis is an affection in most cases appearing before the tenth 
year; it is not a disease of the spine, but the result of mechanical 
forces acting upon a spine which in other than sHght cases must be 
assumed for some reason to be abnormally formed or to possess less 
than normal resistance. It is not, as a rule, accompanied by any 
degree of pain. Stiffness, if it is present, is an accompaniment of 
late cases and the result of long-continued structural changes. 

In the diagnosis of scoliosis the first question that arises is whether 
or not scoliosis is present. A plumb-line is held in the line separat- 
ing the buttocks, and if all the spinous processes lie under that line 
scoliosis is not present. If any number of spinous processes do not 
lie under the plumb-line scoliosis is present. 

If scoliosis is present the question is, is it functional or structural, 
and what is the curve? The diagnostic signs of functional and struc- 
tural curves have been described (pages 5 5 ,61,) and by aid of these 
the curve is classed as one or the other or as transitional (page 57). 
The ends of the spine are connected by a string and the parts lying 
to the right are called right curves and those to the left are called 
left curves. 

If the curve is functional, it is desirable if possible to identify its 
cause ina shortleg, unequal vision, etc. 

. If the curve is structural it is important, if possible, to assign it to 
its proper etiological division. 

Scoliosis of Congenital Origin. — Such curves occur early, are 
often severe, and are identified by the a:-ray. When accompanied 
by gross defects in the thorax or elsewhere they are easily recognized. 

Rachitic Scoliosis. — This form is generally believed of late to be 
more common than was formerly supposed. To establish the diag- 
nosis, other signs of rickets should be found in cases where the 
rickets is general. These are the high square head, the rosary, 
curved bones, enlarged epiphyses and usually somewhat retarded 
general growth. A history of a late first dentition suggests the 

125 



126 DIAGNOSIS 

existence of rickets. But later views ^ are to the effect that mild 
rickets, by affecting the epiphyses between the laminae and bodies 
of the vertebrae, or the bodies themselves, may bring about dis- 
tortion of the vertebrae which is the cause of scoliosis, and that 




Fig. 89. — 'Normal Vertebra Showing Proper Space in Epiphyseal Junction Between 
Pedicles and Body. — Engelmann.) 

grades of rickets which are not severe enough to cause general de- 
formities may thus be a factor in causing scoliosis. The matter is 
not yet sufficiently established to enable one to give clear directions 
as to the x-ray diagnosis of such cases. 

Osteomalacia is uncommon and characterized by severe general 
curvature of the bones and the iic-ray shows a greatly diminished 
bone shadow. 

Infantile Paralysis. — This is a motor paralysis beginning with a 
feverish attack, generally in summer, followed by loss of power in one 
or more limbs. The affected limbs are in the severer cases cold and 
wasted and reflexes are lost. In the severer cases of scoliosis of this 
type the deformity becomes extreme. There are occasional cases of 
infantile paralysis where the attack is sHght and the loss of motion is 
apparently recovered from, but where a lateral curve of more or less 
severity develops later as a result of the paralysis of some spinal mus- 

1 Engelmann, "Zeitsch. f. orth. chir., 1915-16, xxxv, 256. 
Herg, "Thorakoplastik and Skol. Beilagehaft der Zeitsch. f. orth, chir., xlii, 
Stuttgart, 1 92 1. 

Bohm, "Vorhdlg. d. Deutsch. Ges. f. Orth. Chir., 1921, xvi. 



' DIAGNOSIS 127 

cles. The investigation into the history in doubtful cases becomes of 
much importance and the back should be examined in every case of 
infantile paralysis in any part of the body. 

Empyema and pleurisy are recognized as the causes of a severe 
form of scoliosis, especially when a resection of the rib has been per- 
formed in empyema. The curve is always convex toward the unaf- 
fected side of the chest and is dorsal or dorsolumbar. It is identified 
by the scar on the chest or the auscultation signs in the thorax and 
the history of the case. Any other scar of sufficient size is competent 
to produce the same result. 




Fig. 90. — Enlargement of Epiphyses Between Pedicles and Body of Vertebr-<e Due 
TO Rickets. — (Engelmann.) 

Other evident causes of structural scoliosis are sufiiciently indi- 
cated in the table given in the chapter on Etiology. 

Finally, in many cases no evident cause can be found and one is 
obliged to assume that the bones of the individual possess less than 
nornial resistance to weight bearing. 

Pathological Conditions Accompanied by Lateral Curvature as a 
S)maptom. — Cases of lateral curvature accompanied by pain, espe- 
cially if this is exaggerated by motion, should not be given exercises, 
but kept under careful observation until a perfectly definite diagnosis 
has been made. The same applies to slight curves accompanied by 
stiffness of the spine. Doubtful cases may often be cleared up by the 
use of the x-ray. 

These painful conditions accompanied by scoliosis must be care- 



128 DIAGNOSIS 

fully separated from true scoliosis. The chief one of these is PoWs 
disease, or tuberculosis of the spine. The symptoms of this affection 
are stiffness of gait and loss of mobihtyin the spine, pain on motion or 
jar, -and spontaneous pain in the chest and abdomen, elevation of 
temperature, and impairment of the general condition. As the 
disease progresses, a sharp prominence backward of the spinous proc- 
esses occurs at some part of the spine. Lateral deviation of the 
spine occurs in the acute stage of practically all cases, but it is a 
leaning of the body to one side rather than a true gradual curve; 
ther€ is no rotation of note, and the lateral deviation is an index of 
the severity of the disease, disappearing after a period of recumbency 
in bed and being controlled by efficient treatment. The danger of 
mistaking Pott's disease for scoliosis lies in the early cases before the 
knuckle, or backward deformity, has occurred. 

A form of lateral deviation accompanies arthritis deformans of the 
spine, which is also known under the names of osteoarthritis of the 
spine, spondylitis deformans, ankylosis of the spine, spondylose 
rhizomelique, Bechterew's disease, Steifigkeit der Wirbelsalile, etc. 
This is essentially an affection of adult life, but not unknown in 
children. The spine is stiff and painful, the lumbar concavity is 
diminished or lost, and the curve a gradual one with slight or no 
rotation. 

The lateral curves accompanying tumors of the spine, dislocation 
of the vertebrae, etc., would hardly be mistaken for real scoliosis, the 
usual signs of those affections being present. 



1 



CHAPTER XII 
PROGNOSIS 

WITHOUT TREATMENT 

Total curves may remain as such through life, probably increasing 
somewhat; they may change to structural curves; or they may be 
cured by proper treatment, but they are not likely to disappear 
spontaneously. So long as they remain purely functional curves, 
as defined above, they will probably not influence the general health 
unfavorably or produce any unpleasant result further than slight 
asymmetry. In neurasthenic women they are frequently accom- 
panied by backache. 

Structural curves, whether simple or compound, in young children 
should be regarded as serious, as almost sure to increase, and perhaps 
to increase rapidly. They will surely lead to some deformity, and 
perhaps to grave deformity. They are Hkely to affect the general 
health and to shorten life by inducing phthisis and ill health. Adults 
with severe scoliosis are, as a rule, less vigorous than normal. 

Slight or moderate structural curves in older children and adoles- 
cents which have not progressed rapidly through childhood are after 
puberty likely to increase but slowly, if at all, until late middle life, 
when the atrophy of the intervertebral discs is likely to make them 
more evident and troublesome. Severe structural scoliosis at any 
period of life is to be regarded as likely to shorten the patient's life 
and to induce ill health. The rapid increase of a postural or structural 
curve is a threatening symptom demanding attention. 

WITH TREATMENT 

Total scoliosis should be entirely and permanently cured by 
adequate treatment. 

Structural scoliosis in young children when of moderate degree 
should be practically cured by adequate and long-continued treatment 
but only by that. If severe, it should be much improved by the 
same means, the prognosis in both classes being better in children 
with a long period of growth ahead than in adolescents. 

9 129 



130 PROGNOSIS 

Structural curves in older children and adolescents when of moder- 
ate degree should be greatly improved by adequate and long-continued 
treatment, but as a rule cannot be wholly cured. Severe structural 
scoliosis under these conditions can be markedly improved. 

When growth has been reached, only improvement and not com- 
plete cure is to be hoped for from treatment in true scoHosis of any 
but the mildest grade. In adults with severe scoliosis the general 
condition of the patient may be greatly improved by an improved 
position of the spine. In late adult life support of the spine in the 
best obtainable position is the only outlook from treatment, again 
often attended by improvement of the general health. 

ScoHosis due to severe congenital defects of the vertebrae, scapulae, 
or thorax, to infantile paralysis, or to empyema cannot be cured if a 
curve of moderate or severe grade has occurred, but can be improved. 
Rickets contributes a class of cases on the whole resistant to treat- 
ment, and in severe cases, even in young children, a complete cure 
is probably not obtainable. The existence of organic heart disease 
or phthisis makes the prospect of obtaining much improvement 
from treatment unfavorable. 



CHAPTER XIII 
TREATMENT 

The treatment of scoliosis can be most clearly considered if one 
separates for purposes of discussion the two types of cases already 
described (pages 55-61) — (i) the postural or functional, and (2) the 
organic or structural. That such a distinction is not always sharply 
to be made, that transition cases are to be seen, and that many 
therapeutic measures are common to both classes of cases, apphes 
here as in most other departments of medicine and surgery where 
functional and organic conditions are separated. 

To call both of these varieties by one name, scoliosis, leads to 
confusion and contradiction, to widely differing statements as to 
etiology, and to marked divergence of views with regard to treat- 
ment and its results. If we grouped together all sprains and joint 
fractures under the term of ''fractures" without regard to the 
presence or absence of bone injury, our classification and our treat- 
ment of these injuries would become confused, contradictory, and 
unsatisfactory. 

It is clearer to designate as "false" scoliosis the postural variety, 
and as "true" scoliosis the structural variety, so that in the con- 
sideration of etiology and treatment we may not be grouping under 
one name two conditions essentially different. 

True scoliosis constitutes our real problem, of course, but in order 
to make that part of the subject perfectly clear, we must first dis- 
cuss and remove from our field the less difficult question of false 
scoliosis. 

THE TREATMENT OF POSTURAL SCOLIOSIS (FUNC- 
TIONAL SCOLIOSIS, FALSE SCOLIOSIS) 

Regarding the condition as an habitual inability to stand correctly, 
as a postural malposition without marked structural change, it is 
evident that the treatment should consist in the substitution of a 
correct attitude for the faulty one. This is obviously to be preceded 
by eliminating conditions unfavorable to the maintenance of a correct 
upright position. The conditions requiring investigation and pos- 

131 



132 TREATMENT 

sible correction in every case as a preliminary to beginning treat- 
ment are — (i) seats and desks at school; (2) the manner of clothing 
the child; (3) the condition of the eyes and ears; (4) the existence 
of a short leg; (5) overwork or too long hours, leading to persistent 
fatigue; (6) excessive recent growth with consequent impairment of 
resistance. These matters are also of importance in structural 
lateral curvature. Having placed the patient under the most- 
favorable conditions obtainable and having corrected so far as 
possible the defects above mentioned, the patient should work on 
the exercises to be described for from half an hour to two hours a 
day for a period of some weeks, which exercises should not be pushed 
beyond the limit of fatigue. 

If the child's resistance is normal after a period of vigorous daily 
work, of at least an hour after the first few exercises, under the direct 
supervision of the surgeon, which should generally be continued fcr 
two or three weeks, home work under direction of the parents or 
gymnastic teacher may be substituted for it, in the average case, 
with occasional supervision by the surgeon at longer and longer 
intervals. But it is desirable that such patients should be under 
observation for at least a year and in severe cases much longer. 

The length of treatment, the period of the exercises, and the extent 
to which they can be pushed will depend on the vigor of the child, 
half-way measures are not likely to be successful and exercises 
done at home under the supervision of careless parents are less effi- 
cient than those given by persons trained in the art of gymnastics. 
The treatment lies within the range of any good teacher of gymnastics 
who will carry out the instructions of the surgeon. The causes of 
failure are to be found in the fact that such children are generally 
in poor muscular condition and are often overworked at school or 
under unfavorable conditions at home, or that the exercises are 
given too seldom, or inaccurately,, and are not sufficiently vigorous.^ 

If flexibility to one side is limited, i.e., if the child can bend further 
to the right than to the left in a total curve, the flexibility of the spine 
must be made equal. Having restored the flexibility of the spine by 
this means or if flexibility to the two sides is aUke, a treatment differing 
but little from the "setting-up drill" of the army recruit is to be 
instituted. Exercises suitable for the treatment of postural cases 

^ It is absolutely essential to restore normal flexibility to the spine in aU direc- 
tions; otherwise the treatment wiU not be successful. This may be done by 
exercises to be described later, or by passive stretching similar to that used in the 
treatment of the structural type. 



TREATMENT 133 

will be described in connection with the gymnastic treatment of 
structural scoliosis. 



TREATMENT OF STRUCTURAL SCOLIOSIS (ORGANIC 

SCOLIOSIS, HABITUAL SCOLIOSIS, FIXED 

SCOLIOSIS, TRUE SCOLIOSIS) 

• The problem to be met in the treatment of lateral curvature with 
fixed bony changes is a perfectly definite surgical one. A clear 
understanding of the obstacles to be met and of the means at our 
disposal for meeting them is essential to successful treatment. 

The spinal column having curved to one side has, in the course of 
time, become fixed in the deformed position. In addition to the side 
curve, a rotation or twist in the length of the column has occurred at 
the seat of the main and compensatory lateral curves, particularly 
evident in the thorax. As the result of the maintenance of the 
vicious position over a long time, covering part of the period of 
growth, changes in bones, muscles, ligaments, and intervertebral 
discs have occurred. The individual vertebrae have become com- 
pressed on one side and twisted by the rotation. The ligaments and 
muscles have become adaptively shortened on one side and stretched 
on the other, and the intervertebral discs to a greater or less extent 
have become compressed on the concave side of the curve. The 
region of th^ vertebral column involved by the curve has lost its 
normal mobility and is partly or wholly stiff. There are secondary 
changes in the thorax and abdomen and in the contained organs. 

It is obvious that in the upright position gravity works to increase 
the deformity by exerting pressure upon the concavity of the curves 
already atrophied by an abnormal weight bearing. Of the twenty- 
four hours in each day only some ten or twelve at most are normally 
spent in recumbency. During the remaining twelve or fourteen 
hours the vertical position is assumed and gravity is at work. 

The treatment of structural lateral curvature presents, therefore, 
a much more serious and much less encouraging problem than the 
treatment of postural cases, and measures must be vigorous, ade- 
quate and surgically sound to produce a permanently satisfactory 
result. 

The problem to meet in treating these cases is perfectly definite 
and clear. The flexibility of the spine must be increased so that 
an improved position can be assumed and then the spine must be 



134 TREATMZXT 

held in this improved position. The definite surgical indications 
have been obscured by much elaboration and discussion of detail 
and methods, but this is the gist of the whole matter and it cannot be 
too strongly insisted on that increased flexibilty is absolutely 
essential. 

It is e\Tdent, where the pathological changes have reached even a 
moderate degree, that considerable and continuous force would on 
general principles be necessary to loosen the column sufficiently to 
enable it to assume a position approximately normal and also that on 
the forcing into and holding in such a position depends our sole hope 
of any considerable degree of favorable progress, progress necessarily 
due to the adaptive nature of growing bone i.e.. to the fact that in 
its growth it wiU foUow the hues of least resistance. The practical 
question is : how far may we depend on g^mmastic treatment alone to 
accompHsh this? Because gymnastic treatment is the traditional 
one for scoliosis, and is being pursued in this country to-day in the 
great bulk of cases which are treated at all. 

GYMXASTICS 

Gymnastics have a two-fold object — first, to loosen up the curved 
portion of the spine to make an improved position possible, and, sec- 
ond, to aid in retaining the improved position by strengthening 
certain groups of muscles. Most exercises tend in a measure to 
accompUsh both of these, so that a sharp division into mobilizing 
and retentive exercises is not possible, and one can only point out 
that a certain exercise is especially valuable for one or the other 
purpose. 

It is essential to define and Kmit what place gymnastics should 
occupy in the treatment of structural scoliosis. It is ob\dously un- 
reasonable to expect free standing gymnastic exercises alone to 
straighten marked or severe curves or to change the shape of dis- 
torted bones. But after the greatest possible improvement has 
been secured in such curves by more efficient measures one must look 
to gymnastics to develop the muscles which will hold the improved 
position and make the gain permanent after the corrective jacket 
has been graduaUy discontinued. In marked and severe structural 
scoliosis, therefore, g}^mnastic treatment finds its use as supplemen- 
tary^ to forcible correction. 

The purely g}"mnastic treatment of severe structural scoliosis is 
to-day being largely pursued by two classes of persons. First, by 



GYMNASTICS 



135 



irresponsible masseurs and medical gymnasts who hold as a tradi- 
tion that gymnastic exercises are curative or at least helpful in scolio- 
sis and second, by surgeons who do not believe in corsets or supports,^ 
a class diminishing yearly in numbers. The former class serves 
only to bring the legitimate use of gymnastics for scoliosis into dis- 
repute; the latter class use the gymnastics more or less effectively, 
and take a pessimistic view of the results to be obtained in severe 
scoliosis. 

Structural scoliosis is a bone 
problem; a glance at the deformed 
column indicates this, but it has 
been too largely considered and 
treated as a muscle problem. 
Until recently the treatment has 
been an indirect, intermittent, and 





Fig. 91. — Patient with Left Dorsal 
Curve in 1900. 



Fig. 92. — Same Patient in 1905 after Frvi 
Years of Gymnastic Treatment. 



long-continued effort to remedy a bony deformity by muscular 
means. A surgeon would be thought very much behind the times 
who to-day endeavored to correct bony knock-knee or congenital 
club-foot by muscular exercise, yet many an up-to-date surgeon 

iTeschner: "N. Y. Med. Rec," Dec. 6, 1903; Erich: "N. Y. Med. Jour.," 
Oct. 7, 1899. 



136 TREATMENT 

does not hesitate to advocate gymnastic exercise as the sole treat- 
ment of a bony deformity equally severe. The excuse for the use 
of gymnastic treatment under these conditions would be the fact that 
the results obtained by it were so very satisfactory that the practical 
outcome justified us in disregarding sound theory. But proof is 
wanting that this is the case. 

Gymnastic treatment in apparatus was, however, advocated as the 
sole treatment for all cases by such an eminent authority as Schul- 
thess,^ and treatment by gymnastics and braces by an authority of 
such great weight as Lange,^ but neither of these men has published, 
nor apparently has claimed, such results as claimed and published 
by Wullstein,^ Schanz,* Sever, ^ Abbott,^ Lovett^ and others. Nor 
can the author find the publication elsewhere of results from gym- 
nastic treatment which are convincing as to the efficiency of the 
treatment in moderate and severe cases. Still, one must not pass 
too lightly over the opinions of such weighty authorities as Schulthess 
and Lange, and must allow due weight to them. 

If one makes no distinction between false and true scoliosis, and 
classes every lateral deviation of the spine as scoliosis, if he thus 
groups false and true scoliosis together and treats all cases by effect- 
ive gymnastics, the proportion of successful results will be large 
because of the predominance of the milder cases in almost any group. 
But if one uses the gymnastic treatment in a group composed wholly 
of moderate and severe cases of structural scoliosis, the results will 
be widely different from those of the first group. In this failure to 
separate the two varieties much of the contradictory evidence with 
regard to the results of treatment has arisen. Many well informed 
surgeons are deterred from the use of corrective jackets by the fear 
of inducing muscular atrophy of the back. But muscular atrophy 
of the back is quickly recovered from and the deformity is a grave 
one demanding measures which strike at the salient feature — the 
bony deformity. The history of the treatment of moderate and 

1 Joachimthal's Handbuch d. orth. Chir., Bd. iii, iv und v, page 1035. 

2 Lange and Spitzy: "Handbuch f. Khde., Leipzig," 1910, Bd. v, page 140* 

3 Wullstein: " Zeitsch. f . orth. Chir.," 1902, Bd. x, Teilii. 

^ Schanz: "Zeitsch. f. orth. Chir.," 1908, Bd. xxii, page 57. 

^ Sever: "Surgery, Gynecology and Obstetrics," September, 1912. 

^Abbott: "New York Med. Jour.," June 24, 1911, and April 27, 1912. 

^Lovett: "Boston Med. and Surg. Jour.," October 31, 1901, March 17, 1904; 
"Jour. A. M. A.," June 23, 1 906 ;Lovett and Sever: "Jour. A. M. A.," September 
2, 1911. 



GYMNASTICS 



137 



severe structural scoliosis as a muscle problem is a history largely of 
failure or of extravagant and unwarranted claims. 

Not only may gymnastics in moderate and severe structural 
scoliosis fail to do good, but they frequently do serious harm for the 
following reason: scoliosis of this grade soon results in a stiffening of 
the affected region of the spine. If efficient gymnastics are given 
the spine is speedily rendered more flexible and if it is so rendered and 
not supported at once, it will sink into a worse position than before 
and the curve will be increased. The assumption made by the advo- 




FiG. 93. — Trunk Bending Appa- 
ratus. — (Schulihesi.) 



Fig. 94. — Shoulder Pushing Apparatus.- 
(Schulthess.) 



cates of gymnastics is that the back muscles will be so developed 
by the exercises that they will immediately hold the spine in an 
improved position, but this does not happen, and the flexibility in- 
creases much faster than does the holding power of the muscles. 
Much harm would be avoided in the gymnastic treatment of these 
cases if this practical fact were recognized.^ It is a good rule either 

1 Chlumsky: "Verhdlg. d. Deutsch. Ges. f. orth. Chir.," looS. ^^17. 



138 



TREATMENT 



to treat structural scoliosis by adequate and surgical measures, or to 
let it alone — only harm can result from restoring flexibility without 
providing adequate support. 

Place of Purely Gjonnastic Treatment.— In mild structural 
scoliosis efficient gymnastics should constitute the sole treatment, 
and may be continued as the sole treatment so long as the improve- 
ment from one exercise period persists until the next one. If such 
improvement is not held between exercises it must be assumed — (i) 




Fig. 95. — Hip-pendulum and Shoulder-raising Apparatus. — (Schulthess.) 



that the exercises are not good ones; (2) that they are not properly 
carried out; (3) that the amount of treatment is insufficient, or (4) 
that the. case is too severe for purely gymnastic treatment. Progres- 
sive improvement must be assmned as the criterion of efficient gymnastic 
treatment. 

It is impossible to draw a general line either theoretically, or in 
practice at the outset between cases of structural scoliosis which are 
likely to be cured by g\^mnastics alone and those which are not. 
The line comes somewhere between the mild and the moderate cases 



GYMNASTICS IN APPARATUS 1 39 

and doubtful cases should be tried on the purely gymnastic treatment 
and kept on it only so long as they progressively improve. In 
other words mild cases are generally suitable for gymnastic treat- 
ment. Cases of moderate grade with slight rotation and not much 
lateral curve are also to be started on gymnastic treatment for trial, 
cases of moderate grade with marked rotation and curve are not 
suitable for gymnastic treatment alone and all cases of severe scoliosis 
are unsuited to gymnastic treatment. 

Scheme of Treatment. — (i) Gymnastics may be given alone as a 
treatment, under the conditions described above or (2) in cases 
where the patient becomes rapidly flexible or seems to require 
support between exercises, such treatment may be supplemented by 
the use of supporting jackets, braces or corsets. (3) In connection 
with gymnastic treatment intermittent passive stretching is useful 
in restoring flexibility or (4) both corsets and stretching may find 
their use in connection with gymnastics. (5) Finally forcible correc- 
tion should constitute the treatment of most moderate and all 
severe cases in connection with the measures mentioned in (4). 

The use of braces and corsets alone cannot in any way be con- 
sidered a treatment for scoliosis. To make this matter plain the 
following scheme presents the above statements in the form of a 
table: 

, V ^ ^. , / (a) in apparatus, 

(i) Gymnastics alone < .,. -^u ^ 

\ (0) without apparatus. 

(2) Gymnastics and corsets. 

(3) Gymnastics and stretching. 

(4) Gymnastics, corsets and stretching. 

(5) Forcible correction in addition to (4) 

i((z). Gymnastics Given in Apparatus. — By means of apparatus 
gymnastic exercises can be more correctly localized, and the work 
of loosening the spine and of strengthening the desired muscles 
can go hand in hand. This method, which is in general use in Europe, 
has never found a foothold in this country on account of the compli- 
cated and expensive apparatus. 

The system of apparatus devised by Schulthess and its modifica- 
tions, the apparatus of Zander, and the simpler apparatus of Lange, 
are the best examples of the kind. 

The precision of the apparatus, its adaption to anatomical needs, 
and the principle of securing correction and the development of 
desired muscles at the same time make the svstem sound and efficient. 



I40 TREATMENT 

i(b). Gjrmnastic Exercises Given without Apparatus. — This 
method of treatment is the one in most general use in America. It 
is open to the objection that the force exerted is not sufficiently 
locaHzed, but is distributed over the spine. 

Fixation of Pelvis. — It is essential that the pelvis should be fixed 
during such exercises, as otherwise the pelvis is displaced and the 
movement becomes a general and not a local one. A simple wooden 
apparatus may be constructed which holds the pelvis and does away 
with the necessity of holding the hips of the patient between the 
knees, which must otherwise be done. This saves labor on the part 
of the person giving the exercises, and permits a closer supervision of 
the back than is possible when part of the attention must be fixed on 
holding the patient firmly. 

The apparatus, which was suggested by that of Bade,^ consistsof a 
wooden clamp made by two flat boards set at right angles to a hori- 
zontal board on which they slide to hold the sides of a pelvis of any 
width. The whole apparatus moves up and down on an upright 
fastened to a large round floor platform and may be inclined at any 
angle to the horizontal plane. The patient is secured in place by 
sliding in and fastening the lateral clamps at the sides of the pelvis, 
and by securing the front of the pelvis by a broad leather strap pas- 
sing from one arm to the other. The floor platform is so large that 
the apparatus cannot upset (Fig. 98). 

General Routine and Precautions. — It is desirable that the back 
should be exposed during the exercises in order to note the effect of 
each one. For this purpose the patient should wear during exercises 
a loose cotton dressing jacket, fastened around the neck and opening 
in the back. This protects the front of the body but permits inspec- 
tion of the spine. 

Such exercises should be simple and corrective in the strict sense; 
that is to say, an exercise which is of use should be seen to straighten 
the spine visibly. Complicated exercises are dangerous and unsur- 
gical. Work to yield results must be given by a competent gymnast 
for a period of from one to three hours a day, according to the vigor 
of the patient, and must be continued under personal supervision for 
a period of some weeks or months to obtain satisfactory results. 
The average American child is rarely able to do daily more than one 
or two hours of heavy gymnastic work. After this, exercises at 
home can be substituted for part of the personal work. 

^ "Zeitsch. f. orth. Chir.," xii, 4, 799. 



GYMNASTIC EXERCISES 



141 



As a preliminary to gymnastic work the heart of the patient should 
have been, of course, examined. Afterward the weight should 
be taken each week, as persistent loss of weight is an indication for 





Fig. 96. — Composite Photograph (Two 
Exposures on the Same Plate) Showing 
THE Model Standing Erect and Bending 
to THE Right without Fixation of the 
Pelvis. The Movement is a General One. 



Fig. 97. — Composite Photograph of the 
Model Standing Erect and Bending to 
THE Right with the Pelvis Fixed. The 
Movement is Limited to the Spine. 



moderating or discontinuing temporarily the exercises, providing 
that the patient is not being overworked at school, in which case the 
school conditions should first be remedied. During menstruation, 
gymnastic exercises should be suspended. Persistent fatigue, 
anemia, loss of appetite, nervousness, and frequent or profuse men- 
struation should cause a careful investigation of the patient's environ- 
ment, as they may arise from this influence or from excess of gym- 
nastic work. 



142 



TREATMENT 



The following list of gymnastic exercises, selected from a large 
number, may be regarded as representative of the kind of gymnastics 
likely to be of use within the limits mentioned above. They will first 
be described individually and then analyzed, and their application to 
different conditions will be indicated. The selection of exercises 
must depend on the requirements of each case. Simple general 
developmental exercises have not been included here, as a description 
of them can be found in books on gymnastics. 




Fig. 98. — Apparatus for Fixing the Pelvis During Gymnastic Exercises. 

In the explanations to be given in connection with each exercise 
the general mechanical features will be discussed, but it must be 
remembered that conditions observed in the normal do not neces- 
sarily hold true in the deformed spine of scoliosis, although they form 
the best basis for analysis. The more nearly a spine approaches the 
normal, the more likely is such analysis to be correct. 



SYMMETRICAL EXERCISES 

Exercises in the Standing Position 

In all exercises given in this position the pelvis should he fixed unless otherwise 
stated. It must be remembered that exercises in this position call into play in 
varying relations all muscles concerned in maintaining the upright position, and 



SYMMETRICAL EXERCISES 



143 



therefore cannot be as highly specialized as can exercises given in the lying posi- 
tion. It must also be remembered that the superincumbent weight rests on the 
laterally curved spine, and that the curves are therefore not in as favorable a 
condition in such exercises as in the lying position. On the other hand, they are 
useful because any improvement of scoliosis must be interpreted as meaning 
improvement in the upright position, and all muscles concerned in that are 
therefore of importance. 

Fundamental Standing Position. — The patient stands with the knees extended, 
the hands on the hips, the back straight, the head erect, and the scapulae brought 
close to each other. The patient should not exaggerate the lumbar curve, and 
should press down with both hands on the hips. 

I. Trunk Stretching. — (i) From the fundamental standing position the patient 
stretches the whole spine upward. The surgeon holds his hand slightly above 
the patient's head and urges her to stretch until she can touch his hand with 
her head, keeping both heels on the ground. The position of the hand is made 
higher as necessary. (2) From the upward stretched position the patient relaxes 
to the fundamental standing position. In count (i) the patient breathes 
in and in count (2) breathes out (Fig. 99). 





Fig. 99. 



Fig. 100. 



This is a general exercise calling upon the muscles which maintain the proper 
erect position, notably the spinal extensors. The elevation of the shoulders 
elevates and fixes the shoulder-girdle, giving a fixed point for the pull of the 
inspiratory muscles, thus tending to increase chest capacity, and a general 
stretching of the spine is also made easier by the fixed shoulder-girdle. The exer- 
cise is applicable to any case of scoliosis, especially to postural curves, as a general 
mobilizing and corrective one. 

II. Trunk Bending Forward with Trunk Stretched. — (i) The shoulders are 
raised as in Exercise I (i). (2) The patient bends her trunk forward to the hori- 
zontal position, the spine being held straight and the shoulders raised, movement 
occurring only in the hip-joints. (3) The patient raises the trunk to the upright 
position with the shoulders still raised and the spine straight. (4) The patient 
relaxes to the fundamental standing position (Fig. 100), 

This combines the essentials of Exercise I with the weight of the trunk thrown 
on the extensor muscles of the back and on the glutei, which must be held con- 



144 



TREATMENT 



tracted to maintain the forward bent position and which must contract to bring 
the trunk again into the upright position. It has the corrective effect of Exer- 
cise I, in addition to which it is a fairly strong spinal extensor exercise with the 
lumbar curve flattened. It is a general mobilizing and corrective exercise 
which may be safely used in cases with a tendency to exaggeration of the lumbar 
curve. The patient inspires in (i), holds the breath during (2) and (3), and 
breathes out in count (4). 

The above exercises may be modified and made slightly harder by having the 
patient place both hands behind the neck with the elbows squared back as far 
as possible. This raises the center of gravity of the trunk and therefore in- 
creases the leverage against the muscles. 

Exercises Gr'ex in the Horizontal Position 

In this group of exercises one set of muscles may be. more readily picked out 
for exercise than in the erect position. The spine when prone is less curved than 
in the upright position, and is slacker and more easily capable of side displace- 
ment. The fact that symmetrical h5rperextensions are so much used for their 
corrective effect is explained by their empirical value and by anatomical reasons 
(page 32). ■ - 




Fig. ioi. 



Lying on the Face. — IV. Trunk Raising. — Position: The patient lies face 
downward on a table with the spine straight, the hands on the hips, the scapulae 
approximated to each other, and the legs secured to the table by a strap passing 
around the table and legs just above the ankles, or the legs may be held by the 
hands of an assistant, (i) The patient inspires and raises the trunk from the 
table, h>^erextending the spine as far as possible, keeping the head back and the 
face up, wath the elbows still held well back. (2) The patient breathes out and 
sinks to the original position (Fig. loi). 

This is an extension of the spine from its normal position to extreme hyper- 
extension in which the spinal motion occurs largely below the tenth dorsal 
vertebra, where hyperextension anatomically takes place. The weight of the 
trunk is raised by action of the back extensor muscles which are very generally 



SYMMETRICAL EXERCISES 



145 




Fig. 102. 




Fig. 103. 




Fig. 104. 



10 



146 



TREATMENT 



called into play. It is a general strengthening exercise for these muscles, but 
in cases with marked increase of the lumbar curve it must not be used to increase 
this, in such cases Exercise II being available (p. 143). This exercise may be 
modified so as not to increase the lumbar lordosis by having the operator place 
one hand in the middle of the patient's back just below the shoulder blades and 
exert enough pressure to locaUze extension of the spine to the part above her 
hand. Exercise II is probably a weaker exercise, because in it the extensor 
muscles do not contract to their fuUest extent. The exercise may be made 
harder by placing the hands behind the neck and squaring the elbows back or by 
extending the arms beside the head, which raises the center of gravity (Fig. 99). 
The above may be modified in the following manner: The patient clasps his 
hands behind his back above the level of the waist-line, with elbows flexed and 
hand closed against the back, and, as he hyperextends his trunk, stretches his 
arms backward forcibly, extending the elbows, and keeping the hands clasped. 
By this modification the scapulae and shoulder-joints are carried back and the 
hyperextension done with an improved position of the shoulders. This is par- 
ticularly suited to round shoulders. 



( J 




Fig. 105. 



This exercise may be made stronger by the use of dumb-bells or a staff as indi- 
cated in Figs. 103, 104. 

Exercises Lying on the Back. — The patient lies on a table or on the floor with 
the head, trunk, and legs straight, and the feet secured either by a strap or by 
being held. The arms are folded on the chest. 

VI. Trunk Raising to Sitting Position. — (i) The patient rises slowly to the 
sitting position with the spine stiff and not allowed to flex. (2) The patient sinks 
to the primary position with the spine still stiff, the head touching the table 
before the back (Fig. 105). 

The exercise is made easier by placing the hands on the hips, and harder by 
placing the hands behind the neck with the elbows squared back. The upright 
position is brought about by the contraction of the abdominal muscles, which aid 
in maintaining the upright position, and require exercise in cases of prominent 
abdomen and of increase of the lumbar physiological curve accompanying 
scoliosis and round shoulders. 



ASYMMETRICAL EXERCISES 1 47 

Miscellaneous Symmetrical Exercises 

VII. Weight Carrying on the Head. — A bag filled loosely with sand, weighing 
from 3 to 15 pounds, is placed on the top of the patient's head, and she walks 
slowly to and fro with the arms prefer£|,bly clasped behind- the neck and the elbows 
squared back. The exercise may be made more difficult by having the patient 
walk on tiptoe. The attitude assumed should be as erect as possible and the 
weight as heavy as can be carried steadily. 

It is a matter of common information that the habitual carrying of baskets 
and loads upon the head induces an erect carriage and a straight spine. The 
presence of weight upon the head necessitates holding the spine as straight as 
possible under the weight, as it is thus most economically carried, and this in- 
stinctive adjustment to superincumbent weight is depended upon for its correc- 
tive effect. The exercise is suited to mild cases with noticeable bad carriage and 
poor balance. 

VIII. Mirror Self-corrective Exercise. — The patient, bared to the hips, faces 
a mirror in front of which hangs a plumb-line. The patient then stands in such 
a position that the plumb-line cuts the middle of the pelvis, and by a muscular 
effort brings the middle of the thorax and the vertical line of the face as nearly as 
possible opposite the plumb-line, bringing three important landmarks into the 
median line of the body, thus securing an improved position. This is held for a 
few seconds and then the relaxed position resumed. The exercise is repeated 
several times, the improved position being held longer each time. 

The exercise is a muscle training and is not in any way a mobilizing exercise, 
but enables the patient to associate a certain position with a certain muscular 
effort, and is of great value in enabling patients to identify by muscular sense 
the corrected position. The exercise requires but little effort and may be done 
at home without assistance. It may be modified in various ways by adding 
free-arm, staff, or dumb-bell exercises, which change the center of gravity, 
strengthen muscles approximating the scapulae, and prolong the corrected attitude. 

ASYMMETRICAL EXERCISES 

IX. Hip Sinking (Hoffa). — Position: From the fundamental standing position 
the patient advances the foot, on the side opposite to the convexity of the lateral 
curve, forward and outward about two foot-lengths, (i) The patient bends the 
forward knee, sinking the hip on that side. (2) The patient resumes the primary 
position (Fig. 106). 

A passive side correction of the lumbar curve, due to a lowering of the pelvis 
on the side of the advanced leg when the knee is bent. Suitable for lumbar 
curves. 

X. Self -correction (Lorenz). — The patient assumes the fundamental standing 
position and places the hand of the side to which the dorsal spine is convex upon 
the side of the thorax opposite to the greatest dorsal curve; the other hand is 
then placed on the ilium, (i) By a side thrust of the hand on the thorax the 
patient corrects the dorsal curve as much as possible, maintaining the correction 
for a few seconds. (2) The patient relaxes to the primary position. The exercise 
may be modified by placing the hand on the side to which the dorsal spine is con- 
cave on the top of the head, as it thus tends to raise a low shoulder. The rest of 
the exercise is performed as described (Fig. 107). 



148 



TREATMENT 



A side thrust of the dorsal spine with pressure applied to the convexity of the 
dorsal curve against resistance furnished by the other hand on the ilium or the 
head. Suitable for dorsal scoliosis, but not powerful, and useful as a means of 





Fig. io6. 



Fig. 107- 



stretching; chiefly good because it can be done by the patient unaided at frequent 
intervals. Exercises IX and X may be combined for a double curve with one 
element dorsal and the other lumbar. 




Fig. io8 



G.109. 



XII. Trunk Hyperextension "with Side Bending — Lying on the Face. — The 
patient lies face downward on a table or on the floor as described (i) The 
trunk is raised from the table as far as possible by hyperextending the spine. 
(2) From this position the trunk is bent to the side toward which the lumbar 
curve is convex. (3) Position i is resumed. (4) The prone lying position is 
resumed (Fig. 108). 

This exercise is an active lateral flexion of the spine in the position of hyper- 
extension. As hyperextension locks the dorsal region against side flexion, the 
movement is almost wholly confined to the lumbar region. If there is a right- 
dorsal curve in connection with a left lumbar curve, bending to the left, while 
it corrects the lumbar curve, does not at the same time greatly increase the dorsal 
curve, as that part of the spine is locked against side bending. The exercise is, 
therefore, suited not only to lumbar curves, but especially to compound curves 
in both dorsal and lumbar regions. 



ASYMMETRICAL EXERCISES 



149 



XIII. Drawing up the Hip — Lying on the Face. — Position: The patient lies 
prone on a table, holding the end with both hands, the arms extended and the 
spine and legs in a straight line, (i) The surgeon grasps the ankle on the side of 
the lumbar convexity and resists while the patient draws the hip up as far as she 
is able, the knee being kept straight. (2) Position i is resumed (Fig. 109) 

The approximation of the side of the pelvis and the thorax on the side to which 
the lumbar curve is convex is brought about by an active contraction of the 
muscles on the convex side of the lumbar curve which it is desirable to develop. 
The amount of work thrown on these is determined by the amount of traction 
made on the ankle. The exercise is suited to cases of lumbar curves or to the 
lumbar element of compound dorsal and lumbar curves. When a dorsal curve is 
present it should be held against participating in the movement by the operator, 
who sits beside the patient on the side of the dorsal convexity, facing the patient's 
feet, and applies three point pressure to fix the dorsal curve by placing her elbow 
in the patient's axilla on the concave side with her hand pressing the ribs between 
the two curves, while she presses with her hip against the convexity of the curve. 
This leaves the operator with one hand free to resist the movement of drawing 
up the hip. 




Fig. iio. 



XIV.' — Side Flexion of the Trunk from the Side-lying Position. — Position: The 
patient lies on a table with the concavity of the lateral curve downward and the 
trunk projecting over the edge of the table above the pelvis the patient being 
supported in this position and the ankles secured by means of a strap. The spine 
is held in medium extension the upper hand on the hip and the lower hand on the 
back of the neck, (i) The trunk is bent laterally and upward as far as possible. 

(2) The original supported position is resumed (Fig. no). 

In this exercise the weight of the trunk is thrown on the muscles of the convex 
side of the lateral curve. The raising of the trunk tends both to diminish a 
curve existing near the dorsolumbar junction and to exercise strongly the muscles 
which aid in its correction. It is suited to total lower dorsal and dorsolumbar 
curves. 

XV. Trunk Bending to Both Sides ivith Hand Pressure. — For a dorsal curve 
where there is a compensating lumbar curve, (i) The patient lies prone and the 



ISO 



TREATMENT 



operator fixes the lumbar curve by standing on the side of its concavity and 
pressing with one hand against the patient's ribs just between the two curves. 
With her other hand she exerts pressure against the convexity of the lumbar 
curve, at the same time pushing with the elbow of that arm against the patient's 
hip on the concave side. The patient then bends toward the side of the dorsal 
convexity, the lumbar spine being held against participation in the movement. 
(2) The patient stands and leans forward with the spine flexed as much as 
possible. This position is in itself sufiQcient to prevent side bending from taking 
place to any great extent in the lumbar region, but it is well for the operator to 




Fig. III. 



Fig. 1X2. 



Fig. 113. 



hold the lumbar spine by applying three point pressure above and below the 
lumbar curve on the side of the concavity, and over the convexity on the other 
side. The patient then bends as strongly as possible to the side of the dorsal 
convexity. 

XVI. Passive Head Side Bending. — Position: The patient stands with the 
hand on the side of the concavity of the lateral curve against the side of the head 
above the ear. (i) The head is pushed as far as possible to the side that corrects 
the curve. (2) The original position is resumed (Fig. iii). 

A passive correction of the cervical lateral curve by a side bend of the upper 
part of the cervical region which tends to diminish the curve. Of use in cervical 
and cervicodorsal curves, either alone or existing in combination with others. 

XVII. Trunk Raising with Asymmetrical Position of Staff— from Prone Lying 
Position. — Position : The one described for exercises with the patient lying on the 
face with a staff grasped in both hands, the arms being extended beside the 
head, (i) The trunk is raised from the table and the staff brought over 
behind the head obliquely, the hand on the side of the convexity of the curve 
being carried down toward the feet, and the other carried up over the head until 
the staff is brought as nearly as possible into the long axis of the body and pressed 
against the back. (2) By a reversal of the movement the original position is 
resumed (Fig. 112). 

The scapula on one side is raised and the position of the staff tends to correct 
an existing curve in the dorsal region. The exercise amounts to a spinal hyper- 



ASSYMMETRICAL EXERCISES 15I 

extension in a corrected position of the dorsal spine. The exercise is suited to 
total curves, to simple dorsal curves and to compound dorsal and lumbar curves. 

XVIII. Partial Suspension by One Arm with Other Arm and Leg Locked. — 
Position: The patient standing by a ladder or under a bar that can be reached 
without rising on the toes, grasps one rung of the ladder or the bar with the hand 
of the side to which the spine is concave. On the opposite side, the convex, the 
arm passes under the knee, the thigh being flexed at the hip, and the shoulder 
and pelvis are thus approximated, (i) The patient thus standing on one leg 
flexes that knee and allows the body- weight to come upon the arm. (2) The 
original position is resumed (Fig. 113). 

When the arm is placed under the knee the pelvis and shoulder are approxi- 
mated on that side and the spine made convex to the other side as far as it will go. 
The structures on the concave side are thus put on the stretch and, by allowing 
the body-weight to come on the arm holding to the ladder, a further stretching 
force is exerted on the structures on the concave side. The exercise is suited 
to total and dorsal curves. 

Creeping Exercises (Klapp). — In these exercises the patient supports the 
trunk in a horizontal position with the hands and knees or feet on the floor. The 
hands, knees, and toes should be protected by leather pads which are strapped on. 




Fig. 114. Fig. 115. 

XIX, Symmetrical Creeping. — The hand and knee of the right side are placed 
close together with the hand to the outer side of the knee, the head is twisted with 
the face to the right, and the trunk is rotated with the left shoulder upward. 
The left arm is extended beyond the head and the hand placed on the floor, palm 
down and fingers forward, as far forward as possible and directly in front of the 
right knee. The left knee is placed as far back and as near the median line as 
possible; the spine is strongly bent to the right. The creeping consists of forward 
locomotion by a series of reversals and regainings of the position described. The 
mechanism of the first reversal is as follows: the left knee is drawn forward to the 
inner side of the left hand in its original place and position, the right arm is 
extended above the head, and the hand placed as far in front of the left knee 
as possible with the palm down and fingers front. At the same time the spine is 
rotated to bring the right shoulder high, the face is twisted to the left and the 
spine flexed to the left. The restoration to the first position is secured by again 
moving the back knee (right) and the back hand (left) (Fig. 114). 

This is a general muscle strengthening and spine-mobilizing exercise. It is 
comparatively mild and may be continued for long periods of from twenty to 
forty minutes. Symmetrical creeping is properly that which is done rapidly, 
and is of most value in restoration of flexibility. 

A modification is made by creeping slowly, holding each position and putting 
force into the stretching, usually holding the position longest which stretches the 



152 



TREATMENT 



concavity of the most marked curve (Fig. 115). Another modification is creep- 
ing in place, which differs from the above in that the patient does not attempt 
locomotion. The position is somewhat as above except that the fingers of 
both hands are placed on the floor opposite to the side to which the face looks. 
The trunk is rotated till the side with the forward arm is uppermost, and the arm 
is carried directly over the head, while the under arm is flexed at the elbow which 
points to the side toward which the face is turned, the posterior knee is straight- 
ened, and the foot only of that limb touches the floor. The patient then endeav- 
ors to look upward beneath the forward reaching arm. This is best employed 
as an asymmetrical exercise to correct the dorsal convexity and stretch the 
side of the concavity (Fig. 117). 

XX. Creeping Sidewise. — There is a third asymmetrical variation in "creeping 
sidewise" toward the side showing the concavity of the curve to be corrected, for 
example, in a left total curve. The patient creeps sidewise to the right. The left 
hand and knee are placed under the trunk, and as far as possible to the right of the 
right hand and knee. The right hand and knee are then advanced to the right 
and the above is repeated. The face should look to the left (Fig. 116). 

This is a corrective exercise similar to other forms of creeping, and may also 
be used for dorsal curves as well as for those of the total type. 




Fig. 116. 



Fig. 117. 



XXI. Creeping with Arm Flinging Upward. — Another kind of creeping in which 
the upper part of the spine is especially concerned is the creeping with arm 
flinging upward. The starting position is the same as for ordinary creeping — 
hands and knees on floor, hand and knee of one side touching, hand and knee of 
opposite side stretched far apart. The patient brings up the backward knee until 
it touches the forward hand, then raises the opposite hand from the floor, and with 
elbow straight swings the whole arm upward so that the impetus of the swing 
twists the dorsal spine and causes the whole trunk to turn. At the same time the 
patient turns her head and looks up at the hand that is raised. This stretched 
position is held for a second, then the arm is swung downward again and the hand 
placed as far forward on the floor as possible. Fig 117. 



(2) JACKETS, BRACES AND CORSETS 

Braces and corsets of themselves have no place in the corrective 
treatment of lateral curvature, and are only to be regarded as a 
means of retaining the gain secured by other methods. They have 
in themselves little or no strictly corrective value, for such apparatus 



JACKETS AND BRACES 



153 



applied to the spine not previously loosened up by treatment is not 
able to secure any considerable correction by pressure on the spine 
because the base for the leverage to be obtained from the pelvis 
must consist in a pressure obtained from the space between the 
crest of the ilium and the top of the trochanter. Direct pressure 
on the crest of the ilium is not tolerated on account of pressure on 
the nerves passing over the ihac crest (ilio-hypogastric and ilio- 
inguinal), and pressure on the trochanter interferes with walking 




Fig. 118. — On the Left is a Plaster Torso Made from a Corrective Jacket. On 
THE Right is the Same Torso Made More Symmetrical for the Application of a 
Removable Jacket. 



and sitting. It is manifestly impracticable from this small space to 
obtain a hold which will exercise a sufficient side thrust on the thorax 
to be corrective. The current practice of the instrument-makers 
of fitting corsets and braces to such patients and allowing the parents 
to hope for any considerable benefit is therefore to be condemned. 

The complicated braces in former use have been largely displaced 
by the jacket or corset. They may be found described in the refer- 
ences. ^ The corset used in Germany is shown in the illustration 
(Fig. 119). 

In the writer's experience better correction is maintained by 
removable jackets than by braces. A simple quadrilateral brace 
and pad, to be worn over a corset, is shown in the illustration 
and is mildly effective in supporting curves in the middle of the 
spine. Fig. 120,-121. 

^Hoffa: "Lehrb. d. orth. Chir.," fourth ed., 1905, page 429; Redard: "Chir- 
urgie Orthopedique," Paris, 1892, page 382; Bradford and Lovett: ''Orth. Surg.," 
first ed., 1890, page 168. 



154 



TREATMENT 



Under the conditions specified the choice between a removable 
jacket, a corset, or a brace, will be determined by the facility of 
the surgeon in the use of each. 




Fig. 119. — Corset for Scoliosis Strengthened by Steel. — (Dolega.) 



(3) PASSIVE STRETCHING OF THE SPINE 

It is at times desirable to increase flexibility of the spine more 
rapidly than can be done by free standing gymnastics alone because 
stretching of the contracted structures is in all cases of structural 
scoliosis except the mildest more easily obtained by intermittent 
passive stretching in apparatus than by gymnastics alone. The fol- 
lowing considerations bear on the use of stretching force as applied to 
the spine whether in intermittent stretching or in forcible correction. 

The least economical use of force in straightening, for example, a 
bent stick is to pull the two ends away from each other, i.e., to 
straighten it by a pull in its length. The most economical use of 
force is to take it by the two ends and press the point of greatest 
convexity against some resisting point which shall push it straight. 

Again, if one wishes to secure the greatest side displacement in a 
flexible rod, such displacement is more easily secured when the rod is 
not stretched in its length. If a rubber tube, for example, is fastened 
to a table by two pins, one at each end and is not put on the stretch, 



STRETCHING OF THE SPINE 155 

the middle of it can easily be pulled an inch to one side by the fore- 
finger. If, however, it is pinned to the table by two pins one at 
each end separated enough to hold it on the stretch, it will require 
much more force to displace it one inch to the side. The same is 
true of a strip of sponge rubber or a piece of rattan. 




Pig. 120. — Quadrilateral Back Brace for Right Dorsal Curve. Seen from the 

Side, See Fig. 121. 

To be sure that this theoretical consideration applied to the human spine the 
following experiment was made at the Harvard Medical School by the courtesy 
of the late Prof. Thomas Dwight. 

Head suspension is a passive stretching of the spine, corrective through its 
entire length, tending to improve both rotation and side deviation at the curves, 
but exercising still more force upon the more nearly normal parts of the spine 
because the latter are more movable. Suspension by the arms is less ethcient, 
and does not afifect the cervical vertebrae as does head suspension. 

A young male cadaver was laid on the face, and straps passed around the body 
at the level of the right shoulder and the right hip. These straps were then 



iS6 



TREATMENT 



fastened to the left side of the table, holding the shoulder and hip against pres- 
sure from the left. A strap was then passed around the left side of the thorax 
and by rheans of a spring balance pulled to the right. The side de\dation of the 
spine was then measured at four levels, the measurements being taken from a 




Fig. 121. QUADRALATERAL BaCK BrACE FOR .RIGHT DORSAL CuRVE. 

Back, See Fig. 120. 



Seen- from the 



base-line connecting the cervical spine and the sacrum. The measurements were 
all made from pins driven into the spinous processes. Three experiments were 
made with a side pull of 25 pounds and the results were recorded. 

A Sayre head-sling was then put around the head of the cadaver still lying 
on the face, and a traction force of 75 pounds was made in the length of the 
spine, the feet of the cadaver being fastened to the table. While the traction 
on the head was thus in force the same side pull of 25 pounds was made as before 
and the results noted. Two experiments of this sort were made. It was found 
that the spine without traction was displaced to the side nearly twice as far by a 
definite side pull as by the same amount of side pull when traction was 
being made. 

A confirmatory experiment was made on a health}^ boy of fifteen, using 75 
pounds of head traction and 15 pounds of side pull. The result was the same. 



STRETCHING OF THE SPINE 



157 



The conclusion is that extension of the spine by an upward pull on the head is a 
corrective force in the normal spine, but that much more force is required to 
accomplish a certain amount of side correction than is the case if the force 
is applied from the side. 

The other conclusion is that to secure the maximum of side displace- 
ment from a given amount of side 
pressure the spine must be slack and 
not stretched in its length. 

Passive Stretching by Sus- 
pension. — The patient stands 
or sits erect, and the head is 
pulled vertically upward by 
means of a Sayre head-sling, 
which embraces the chin and 
occiput. Traction should be 
made by a compound pulley, 
and the patient or the surgeon 
may hold the rope. Suspen- 
sion is mildest — (i) when the 
feet are not made to leave the 
floor; the next in grade comes 
(2) the position of tiptoe indu- 
ced by the traction, and (3) a 
greater pull is secured by lifting 
the whole body until the feet 
swing free. In this case the 
traction force equals the body- 
weight. The maximum trac- 
tion can be secured (4) by 
strapping the thighs down to a 
seat on which the patient sits. 
An upward pull greater than 
the body-weight can now be 
exerted on the head (Fig. 122). 

Apparatus for the purpose has been devised, and is known as the 
Weigel-Hoffa frame, in which the patient is suspended by the head, 
while pads are run in from the sides of the frame, making lateral 
pressure on the trunk in various directions. 

Correction in the Horizontal Position. — Correction of the lateral 
curve of the spine is, however, to be obtained more economically by 
having the patient lie prone, and the corrective force should be 
divided into two elements, the force to correct the rotation and the 




Fig. 122. — Head Traction. 



iS8 



TREATMENT 



force to correct the side deviation, 
is as follows (Fig. 123): 



A simple apparatus for this 




Fig. 123. — Stretching Board with Loops, Ready for Application. — {"Jour. Am, 

Med. Ass'n."') 




Fig. 124.- 



-Stretching Board with Loops Applied to a Patient. 
C'Jour. Am. Med. Ais'n.") 



Reverse of Fig. 129. 



The patient lies face downward, with the knees flexed, on a board or table three 
feet wide by four feet long. Assuming the case to be of a right dorsal curve, a 
broad canvas strap is passed around the left thorax, over and under the patient, 
and fastened to a cleat on the right side of the board. This furnishes a point of 
pressure to the left against the upper thorax at the level of the axilla. A broad 
canvas strap is then passed around the pelvis of the patient above and below, and 
is fastened to a cleat at the right side of the board. This furnishes a point of 
pressure to the left at the level of the pelvis. A broad canvas strap is then passed 



FORCIBLE CORRECTION 1 59 

around the thorax at the level of the greatest point of curve; it passes above and 
below the thorax and its upper end is fastened to a cleat at the left side of the 
board (Fig, 1 24) . Its lower end is fastened by means of a string into a compound 
pulley attached to a cleat at the left side of the board. By means of this pulley 
any reasonable degree of force may be exerted against the right side of the thorax, 
pulling it to the left, and at the same time that it pulls, it tends to reduce the 
rotation from the fact that its upper end is fastened and its lower end moving 
toward the pulley. The stretching may also be accomplished with the patient 
lying on the back, but it is advantageous to have the back visible during 
the stretching as it enables one to estimate more satisfactorily what is being 
accomplished. 

(S) FORCIBLE CORRECTION 

In marked moderate and in severe structural lateral curvature no 
means of treatment is in the opinion of the author so efficient as con- 
tinuous stretching by means of plaster jackets applied under force. 
This method is spoken of as ''forcible correction." Such jackets are 
applied with the purpose of stretching the contracted structures and 
of inducing an improvement in the curve. 

From the time of the elder Sayre, who advocated for scoliosis the 
application of plaster jackets applied in mild suspension, in several 
papers between 1875 ^^^ ^^^5, there had been sporadic attempts at 
the use of continuous mild corrective force in the treatment of scolio- ' 
sis. Dating from the work in 1869 of Calot^ who advocated at that 
time the use of forcible correction in the treatment of Pott's disease, 
the attempts became more forcible. Schanz^ published in 1900 an 
account of an efficient technic in suspension, and reported results 
in 1902. In 1901 the author reported results and described a technic 
where the patient lay on the face during the application,^ and there 
were other papers written at about this time, but the great impetus to 
the treatment by forcible correction came from Wullstein,^ who read 
a paper at the International Medical Congress in Paris in 1900, and 
who published his experiments, method, and results in 1902. He 
showed experimentally that bony scoliosis could be produced in 
young dogs and by the use of plaster-of-Paris jackets applied to sco- 
liotic patients in an improved position, induced by the use of traction 
and lateral pressure, both of high degree, he secured results that were 
better than any previously reported. The work attracted much 

1 Calot: "France Med.," 1896, 52; 12th Int. Med. Congress, Moscow, 1S97. 
^Schanz: "Munch, med. Woch.," 1900, Bd. xlvi. 

'Lovett: "Trans. Amer. Orth. Asso.," 1901, vol. xiv; "Boston ^led. and 
Surg. Jour.," October 31, 1901. 

" "Zeitsch. f. orth. Chir.," 1902, Bd. x. 



l6o TREATilEXT 

attention, and markedly modified the whole point of ^-iew with 
regard to "forcible correction," which began to gather a body of 
adherents whose number has steadily increased. 

It is desirable where possible to precede the forcible correction by 
a week or two of hea\y g3Tnnastic work given to increase the flexi- 
bility. This is likely to make the apphcation of the jacket more 
effective and more comfortable to the patient. 

The object of the corrective jacket being to force the spine into 
the best obtainable position, and in that position to apply a retentive 
plaster jacket, it becomes pertinent to inquire in what position and 
by what technic the best corrected position may be obtained. 

The chief positions to be considered are (a) in suspension, ib) lymg 
on the face, (c) h^ng on the back. The apphcation in a stated posi- 
tion of the spine has been advocated by Forbes- and with the patient 
hing on the- side by Rich.- 

Applkatioii in Suspension. — The original Sa}Te jackets were 
apphed with the patient suspended by the head with the heels lifted 
from the ground, and he claimed for them nothing more than support 
in an improved position. The jackets were removable, and exercises 
were done dail}-. The treatment was too mild to be effective, and 
although extensively used was not followed by xtry successful 
results. 

Wullstein's method was also a suspension method, but he used 250 
pounds of traction, and to secure this, the patient was strapped by 
the thighs to a revohing and tilting stool and lateral pressure was 
secured by pads running in from an upright frame on horizontal rods. 
These pads were incorporated in the jacket. Much greater force was 
used than ever before, and although unpleasant symptoms from pres- 
sure arose at times, the results were so good that the method was 
extensively used. 

The method of Schanz is simpler and in connection with the after- 
treatment highly efficient if one may judge by the admirable results 
obtained, but at the same time an amount of traction is used which 
is objectionable if the same results can be obtained by other means. 
The patient stands and the ankles are fastened by anklets to rings 
bolted to the floor. By means of a Sa^Te head sling extension is pro- 
duced by means of a windlass to the point of the patient's tolerance. 

^ Forbes: "X. Y. Med. Joum.," July 6, 1912; Maidermot: "American Joum. 
of Orth.. Surg., Feb., 1913; Forbes: "SurgerA', G>ti. and Obst,,'" April, 1914; 
Adams: "American Joum. of Orth. Surg.," July, 1914. 

-Journ. A. M. A., Dec. 30, 191 1. 



FORCIBLE CORRECTION l6l 

A plaster jacket including the shoulders is then applied and as it is 
hardening the surgeon passes his arms around the pelvis of the patient 
arid with his shoulder protected by a pad, presses against the rotated 
and curved portion of the spine. The after-treatment followed by 
Schanz consists in prolonging recumbency in a corrected posterior 
plaster-of-Paris shell with head traction. The patient is turned once 
a day onto the face to have the back massaged, but no exercises are 




Fig. 125. — Patient with Plaster Jacket Applied in Wullstein's Apparatus. 

iWutlslein.) 



given at this period. After months of recumbency a corset and 
headpiece are applied and the patient allowed gradually to sit up. 
At a later period exercises are begun. 
11 



l62 



TREATMENT 



Advatnages and Disadvantages of Suspension Positions. — The use 
of strong traction in the length of the spine tends to straighten the 
lateral curves and to diminish the rotation, but without added lateral 
pressure sufficient correction is not obtained. Moreover, traction 
in the length of the spine makes it resistant to side displacement 
from lateral pressure, as a stretched spine is less easily displaced to 
the side than a slack spine. Wullstein found that he must diminish 

the traction on the head to 
get the best results from side 
pressure. 

But the upright position is 
the one in which the patient 
will wear the jacket; the technic 
of application is in this position 
the simplest, access to the 
shoulders and neck is easy, and 
the lower part of the jacket can 
be accurately fitted to the 
pelvis. Under these conditions 
a close-fitting and presentable 
jacket can be most easily 
applied by this method. 

Application of Corrective 
Jacket in the Prone Position. — 
When corrective jackets, are 
applied to the patients in this 
position, it is desirable to [flex 
the legs, as this diminishes the 
physiological curves of the 
spine and simplifies the 
problem. With a patient thus 
lying prone, the spine is open 
to inspection and is relaxed. 
In this improved position the 
jacket is applied. 
A simple application of this method is to be found by having the patient lie 
prone in a rectangular gas-pipe frame on two straps of webbing running from 
end to end, cross straps supporting the pelvis and shoulders. By means of web- 
bing straps attached to the side of the frame, in a right dorsal curve, one going 
around the left side of the pelvis and another around the left upper thorax, while a 
third pulls on the right side of the thorax against these as points of resistance, 
great force may be exerted on the spine, much more force than can be'^safely used. 




Fig. 126. — Patient Thirteen Years Old. 
Curvature Due to Rickets; Never 
Treated. 



FORCIBLE CORRECTION 



163 



With the patient lying prone on the webbing strips which are padded, the pelvic 
and axillary straps are adjusted to the proper tension and tied around the side 
of the frame. A heavy pad of felt is then applied over the rotated and curved 
portion and a webbing strap attached to the side of the frame and tied at one 
end. This strap is then passed over the rotation, under the patient and back 
to the frame. By pulling on this end of the strap (the upper end of which 
has already been tied) the curved portion of the spine is pulled to the side and 




Fig. 127. — Patient Lying in Cor- 
rective Frame, Showing the Improve- 
ment Gained by the Horizontal 
Position. 

Photograph taken from above. Patient 
same as in Fig. 126. 



Fig. 128. — Patient in Correctwe 
Frame with Side Pressure Applied. 
BY Strap. 

Showing additional correction to 
that in Fig. 127. 



the rotation acted on by the twisting action of the strap. When sufficient 
tension has been obtained the end of the strap is fastened to the frame. The 
jacket is then applied with the side webbing straps in place, the bandages being 
worked around the straps. When the plaster is sufficiently hard these side 
straps are cut off where they emerge from the jacket and a finishing bandage 
applied. The patient then stands up; the longitudinal straps are pulled out, 
the jacket is cut out under the arms and by plaster bandages the jacket should be 
extended to include the shoulders, which is always desirable, but not always tol- 
erated. 

Mechanics and Technic of Application of Jackets in Prone 
Position. — When it comes to the application of corrective force 
it must be remembered that there are two elements in the deformity, 
namely, side deviation and rotation. A single correcting force 



164 



TREATMENT 



would therefore have to be oblique, e.g., in a right dorsal curve for- 
ward and to the left. But for practical purposes it is desirable to 
use two forces, one forward and one laterally toward the spine, 
thus dealing separately with the two elements of the deformity. 
To attempt to correct the side curve by lateral pressure without 
attacking the rotation is likely to result in increase of the rotation 
by pressure on the already flattened shafts of the ribs: 

That this is not new may be 
appreciated by a quotation from 
Schreger^ in 1810: ^' Der seitliche 
Druck auf die Rippen biege diese 
an den ohnehin schon mehr spitzen 
Wikeln noch mehr spitzig zu.^' 
That plaster jackets may cause 
increase of the rib angles is demon- 
strated by Hiissey.^ The same 
point, that plaster jackets may in- 
crease the bony rotation apparent 
in the back, has been alluded to by 
Schulthess and Vulpius.^ 
\ \ -'-^ may, therefore, be stated 

that attempts to diminish the 
lateral curve, by pure lateral pres- 
sure, not carefully antagonized, 
will result, in fixed curves, in an 
increase of the rotation. 

The solution lies in dealing sepa- 
rately with the rotation and with 
the lateral deviation. Having corrected the lateral deviation first, 
this correction is held, as will be described, while the rotation is 
corrected or vice versa. In this way one element is not improved at 
the expense of the other. 



V V 



Fig. 129. — On the Left is a Diagram 
Showing a Right Dorsal Left Lumbar 
Curve. 

In the middle diagram the curve is 
shown straightened; on the right the 
curve has been pushed over to the left 
unchanged. 



Technic of Application. — The patient should preferably be stretched once or 
twice daily for a week or two preliminary to the correction, but this is not 
essential. Anesthesia is never necessary, as all endurable correction may be 
obtained without much pain. A seamless undervest is put on and the iliac 
crests padded with heavy felt; a pad should also be placed over the sacrum. 
Under the side straps heavy felt or cotton pads are required. 

^ Fischer, quoted by Hiissey. 

^Hiissey; "Zeitsch. f. orth. Chir.," viii, 2, 235. 

^ Vulpius: "Volkmann's Samml. klin. Vort.," 276. 



PLASTER JACKETS 



I6S 



The correction is pushed to the point of causing mild discomfort, and difficulty 
in breathing is a sign of too much correction. The amount to be obtained in any 
case is better decided by the patient's sensations than by any theoretical stand- 
ard. The danger lies on the side of obtaining too much rather than too little 
correction, for the jacket will be much more uncomfortable when the erect posi- 
tion is assumed. 

After correction the patient should remain in a hospital under close obser- 
vation for at least twenty-four hours. Some shock is not infrequently experi- 
enced and in a case of the writer's very serious collapse and cyanosis followed 
the correction of a severe curve due to infantile paralysis in a child of six. Wull- 
stein has recorded the occurrence of somewhat serious symptoms following 
correction by his method. 




Fig. 130. — Patient of Whom Radiograms were Taken before Treatment. (January, 
1906). — {"Jour. Am. Med. Ass'n.") 

Advantages and Disadvantages of the Prone Position.— The spine 
in this position is slack and easily displaced to the side and twisted, 
and the back is in view of the surgeon during the application, enab- 
ling him to see just what correction is being accomplished. But 
jackets applied by this method are clumsy, as it is difficult to fit the 
pelvis accurately, especially if the thighs are flexed, access to the 
chest and shoulders is not easy, and the front of the jacket is con- 
cealed from the surgeon's view. 



1 66 TREATMENT 

Application of Jackets with the Patient Lying on the Back. — 

The patient, prepared as for application in the prone position lies 
on the back on a gaspipe frame, to the sides of which transverse 
webbing straps have been fastened and drawn tight, thus support- 
ing the patient. One should pass behind the head, one behind the 
scapulae, perhaps another in the middle of the back, one under the 
pelvis, and others to support the legs and feet. Traction straps are 
applied as in the prone position, the curve is corrected as much as is 
practicable and the jacket is applied. 

The advantage of the position seems to be that the spine is even 
more slack than in the prone position and that, for this reason, side 
displacement is more easily obtained in many cases, and the position 
is more comfortable and less terrifying to children. The disadvantage 
is that the back is not open to inspection during application and one 
has to judge what correction is being obtained by changes in general 
contour, rather than by direct inspection of the spine. 

In the choice between these two, there is apparently no great 
difference in effectiveness. 

Application of Jackets Lying on the Back with the Spine Flexed 
{Abbot fs Method).'^ — The patient lies on the back with the legs flexed 
on the trunk, the back rests on a hammock about a yard long and 
fifteen inches wide cut obliquely across one end. This hammock is 
fastened at each end to a steel rod by which it is loosened or tightened. 
It is held in place by being slung between the ends of a gas-pipe frame 
about five and one-half feet long and two feet wide. This frame rests 
on four gas-pipe legs and has a bar running lengthwise in the middle, 
about two feet above the main level of the frame to" which the legs are 
slung, and nearer the ground are side bars to which straps may be 
attached. The patient is padded with thick felt and laid on the 
back on the frame and the legs are flexed and fastened to the upper 
rod, the shorter side of the hammock resting against the bulging ribs, 
a crosspiece of webbing supports the neck. Cross straps are now ap- 
plied around the body to pull in the desired direction, one in the 
axilla of the low shoulder carried obliquely across the frame to the 
upper corner, another around the pelvis pulling across to the same 
side of the frame as the axillary strap, another strap is passed over 
the most convex part of the dorsal lateral curve to the opposite side 

^Abbott: "Simple, Rapid and Complete Reduction of Deformity in Fixed 
Lateral Curvature of the Spine," "N. Y. Med. Journ.," June 24, 191 1. "Forcible 
Correction of Lateral Curvature of the Spine, a Simple and Rapid Method of 
Obtaining Complete Correction," "N. Y. Med. Journ.," Apr. 27, 1912. 



CHOICE OF METHOD 1 67 

of the frame to pull on the dorsal curve and a fourth strap, wider 
than the others, may be used to pass from the side of the frame 
running over the anterior protruding ribs and hanging down. To 
this weights may be attached to influence the rotation. A large oval 
felt pad is placed over the back of the thorax on the side where the 
ribs are depressed. The straps are tightened and the jacket applied. 
In trimming the jacket it is left long behind at the bottom to main- 
tain flexion of the spine; at the top it is left high under the arm which 
has been elevated, but is cut away on that side in front; beneath the 
other arm it is trimmed low but left high in front to hold that 
shoulder back. A large window is cut in the back over the concave 
side, reaching well around to the side so that the spine may swing 
not only back but to the side, on the opposite side in front a window 
is cut to allow the depressed ribs on that side to bulge anteriorly. 
After the jacket has been worn for a short time pads of felt are in- 
serted in front to push the ribs back through the window cut behind 
and sometimes pads are also to be used over the convexity at the 
back. 

CHOICE OF METHOD 

In choosing between these methods it is probable that most of 
them are efficient and that the especial technic employed is probably 
less important than the skill of the surgeon and his experience with 
the particular method employed, the amount of force used and the 
efficiency of the after-treatment. But one fact must be borne in 
mind, there are two kinds of correction, one a real correction of the 
spine of which the x-ray is the only criterion, and second, an apparent 
correction in which the thorax is rotated on the spine with great 
improvement and perhaps even overcorrection of the body outlines 
but in which an x-ray shows the lateral curve to be largely or wholly 
unchanged. In other words it is easier to rotate the thorax on the 
spine than to change the curve of the spine itself and herein lies 
the weakness of the method advocated by Abbott in which the thorax 
is most easily to be rotated on the spine — apparent correction, that 
is, correction of body outline, has figured in many reported cases in 
which the x-ray has not been shown and where progress has been 
judged only by photographs. An instance of this is given in the 
figures (Figs. 144 and 145). The prone lying and suspension 
methods do not render the thorax so easily movable on the spine 
and it is probable that force expended in correction is more nearly 
spent on the spine itself. 



1 68 TREATMENT 

As to the overcorrection of the curve in marked or severe struc- 
tural scoHosis, such a claim must be substantiated by very weighty 
evidence for such an overcorrection would be contrary to all that 
we know of bone pathology, and a claim of such overcorrection is not 
lightly to be accepted. Abbott's claim was as follows i^ "In a 
previous article on this subject^ the statement was made that fixed 
lateral curvature of the spine yielded to treatment as easily as bow- 
legs or club-feet. Further experience has led me to believe that this 
deformity yields more readily than either of the others." 

A committee of the American Orthopedic Association appointed 
in 1913, sent out in June, 1915, a questionnaire to fifty members of 
the association asking two questions viz.: 

"1. Have you personally had cases of undoubted structural scoliosis in which 
unquestionable overcorrection was obtained? 

"2. Have you succeeded in bringing about a definite cure of undoubted 
structural scoliosis . . . Some of their conclusions from the replies were 
as follows: 

" But one man in fifty has claimed without qualification to have brought about 
a definite cure of undoubted structural scoliosis. Although he was immediately 
requested to furnish the evidence and although he had volunteered to do so, 
the committee has not received it. The committee therefore concludes that of 
the fifty men who have replied to the postal card questionnaire, none are in 
possession of material evidence with which to give an affirmative answer to 
questions i and 2 . . . 

"Note. — Since the completion of the report the one definite and unqualified 
claim of cure in undoubtedly structural scoliosis has been retracted by letter to 
the committee."^ As Abbott claimed complete correction of severe deformities 
in his original paper, his method has been especially looked into. 

The two most careful studies of this method, apart from Abbott's 
own articles, are by Lance of Paris and Kleinberg of New York. 
The conclusions of Lance ^ were as follows: 

"In the cases where there is no marked bony lesion one can always accomplish 
correction and hypercorrection of the lateral deviation. In the cases where 
there are bony lesions in a single curve without compensatory curves, or with a 
compensatory curve not presenting deformed vertebrse, one observes this — that 
the principal curvature diminishes in all the vertebras which are not deformed, 
and there remains a little curve of two, three or four vertebrae in height, composed 
of cuneiform and rhomboid vertebrae, and above and below at rather a brusque 
angle are formed very extensive compensatory curves. We have never been 

1 "N. Y. Med. Journ.," Apr. 27, 1912. 

2 "N. Y. Med. Journ.," June 24, 1911. 

^ "Am. Journ. of Orth. Surg.," July, 1915, page 18. 

^ Lance,: Le Traitement des Scoliosis graves par la Methode d'Abbott. Paris, 
1914. 



DISCUSSION OF METHODS 



169 



able to obtain more. Abbott says that he has obtained complete redressment 
and hypercorrection of scoliosis with vertebral deformity, but he has never pro- 
duced radiographs demonstrative of the fact. ... In the very severe cases, 
where the vertebral deformities exist not only in the upper curve but on one or 
two of the compensatory curves the action is very limited, and one will only 
obtain a result very slightly marked, and which will have very slight chance 
of being maintained." 

Kleinberg/ from an analysis of 60 cases, reaches the following 
conclusions: 




Fig. 131. — Patient Shown in Fig. 130 after Wearing Corrective Jacket for over 
A Year. (March, 1907.) 



"As might have been expected, it was found that the deformity even in its 
mildest form, did not yield rapidly to the Abbott treatment, and that it took 
months to effect any real change. Of the 60 cases, 18 . . . gave up treatment, 
8 were not improved at all, and 34 were definitely made better in external 
appearance, with or without a corresponding change in the spine itself. Of 
this latter number 6 cases relapsed. This method, therefore, is applicable 
to the milder degrees of rigid scoliosis, most of which the writer has seen improved, 
though he has not yet seen any case, no matter how mild, cured, that is, trans- 
formed into one with a perfectly symmetrical back." 

1 ''American Journ. of Orth. Surg.," June, 1014. 



lyo TREATMENT 

Taking all this evidence which is wholly in accord with the writer's 
own experience one must fairly conclude that the situation is much 
what it was before the announcement of Abbot's claims. 

The method is evidently no cure all, and his claims have apparently 
not been substantiated by others. 

The method of Abbott may be a little more or a little less effective 
than the suspended or prone lying positions, the scoliosis Committee 
of the American Orthopedic Association in their admirable report 
said: "It seems probable that greater degrees of correction may be 
obtained with the flexed position of the spine than with the extended 
position of the spine. '^ 

Personally the author would regard the fully flexed position as the 
one in which it is easiest to secure an improvement in body outline 
for the spine thus seems to be more flexible to manipulation and 
it may also be the position in which the greatest real correction of the 
spine is to be obtained. But although one hesitates to generalize 
from a single instance, certain doubt was thrown on the latter point 
by an observation of the author's in which ic-rays were taken of a 
boy with scoliosis in the Abbott position and in the prone lying posi- 
tion with the same ailiount of lateral pull. The prone position 
showed slightly more spinal correction but such an observation 
would have to be confirmed to be convincing. For the present 
we need accurate data in the way of .T-rays; photographs as explained 
are misleading, and impressions of little value. 

The choice therefore must be left to the individual surgeon, 
as to his preference between head suspension, prone lying, lying on 
the back and the flexed position lying on the back. 

TREATMENT SUBSEQUENT TO APPLICATION OF JACKET 

Starting from the application of the corrective jacket three 
methods of treatment are available; (i) the original jacket may be 
left on; (2) after one or more corrective jackets have been applied 
a removable jacket or corset or brace may be used; or (3) in moderate 
cases which have been loosened up by preliminary gymnastic exer- 
cises the original corrective jacket, applied in the suspended posi- 
tion, may be immediately removed to serve as the model for a- 
removable jacket. 

Permanent Corrective Jackets. — When the jacket is hardened, it 
is left solid over the parts that are' made prominent by the rotation 
behind and in front, that is, in a right dorsal curve the right back 



PERMANENT CORRECTIVE JACKETS 



171 



and left front are not touched, but large windows are cut over the 
depressed side of the chest behind and the corresponding portion 
diagonally opposite in front, so that in a right dorsal curve the left 
side would be cut out behind and the right side in front. This makes 
it possible for the depressed parts of the chest to be expanded by 
respiration, while the prominent parts are compressed. Pads of felt 




Fig. 132. — Radiogram of a Patient Seventeen Years Old (Fig. 130) Lying on the 
Back, before the Application of Jacket. (January, 1906). — ("Jowr. Am. Med. Ass'u.") 



are now inserted between the prominent part of the chest behind and 
the jacket, and in the corresponding region in the front, thus making 
the jacket more corrective, and thicker pads are substituted each 
week without changing the jacket, these being drawn through with- 
out difficulty by means of a bandage. In this way, a continual 
diagonal side-pressure is kept up on the curved portion of the spine 



172 



TREATMENT 



and is steadily increased. When these pads have become so thick 
that the jacket is pushed away from the patient and no longer fits 
it will be found that it is advisable to apply a new jacket, to cut it 
out in the same way and to continue the progressive padding. The 
use of such a permanent jacket may be continued as long as it seems 




Fig. 133. — Radiogram of Same Patient as Shown in Fig. 132 Taken after the 
Application of a Plaster Jacket through Windows Cut in Front and Back of 
Jacket. (January, 1906). — {'"Jour. Amer. Med. As^'n." 



possible to gain further correction, being changed at intervals, and 
at the end of this time a removable jacket is substituted for the 
permanent one and gymnastic treatment is begun. The removable 
jacket is then gradually discontinued while the patient's muscular 
condition is being improved by gymnastic exercises. 

Removable Jackets. — The treatment, by removable jackets, is 
best started by the appHcation of a forcible jacket either in recum- 
bency or suspension. This may be followed by a second forcible 



CORRECTION OF TORSO 



173 



jacket at an interval of a week or so, if it seems advisable. For the 
construction of the removable jacket, the patient is suspended, 
a plaster jacket is applied which is immediately cut off to serve as 
a mold, and a forcible jacket applied, to be worn while the re- 
movable apparatus is being made. The jacket which is to serve as 
a mold is then bound together and filled with plaster of Paris and 
water, a torso thus being obtained. This torso is then remodeled by 
cutting off on the prominent side and building up on the other side, 
until it has become decidedly more symmetrical than the patient. 
It is also sawed in halves at the waist and set apart about an inch 
in order to secure continued extension of the trunk. 




Fig. 134- 



-Radiogram of Patient Shown in Fig. 132 after Wearing Correctr-e 
Jacket for over one Year. (March, 1907.) 



On this corrected torso a plaster jacket is applied which is to be the 
removable jacket worn by the patient. This removable jacket 
should be supplied with shoulder pads, to hold the shoulders back 
in position, and should open down the front, being supplied with 



174 



TREATMENT 



buckles and straps or lacings. It is generally advisable to slash 
such jackets over the iliac crests in order to prevent chafing. The 
addition of 5 per cent. Portland cement to the plaster with which 
the jacket is made gives greater strength and durabihty. This 
jacket is to be worn by the patient night and day and to be removed 
only for the exercise period, which should consist of one hour or more 
daily, the exercises being of the type mentioned above. When the 
jacket is applied, it is sprung open and slipped on the patient, who 
then lies on the back, while the arms and legs are pulled on to extend 




Fig. 135. — Permanent Corrective Jacket Applied. 



the spine. It is then buckled tightly in place before the patient 
stands up. Such jackets may be made more effective by padding 
inside of the jacket over the convexity of the curve and cutting a 
large window on the side of the concavity. 

Jackets of either kind should be tested for efficiency by measuring 
the height of the patient with and without the jacket. Without the 
jacket the patient places the hands on the hips and pushes up, mak- 



MECHANICAL OBJECTIONS 



175 



ing himself as tall as possible, and his height is taken in this posi- 
tion. The jacket is then applied and the patient's height is again 
taken. If the jacket does not hold him in as good a position as esti- 
mated by the greatest height the patient can possibly assume with 
the hands on the hips, it is discarded and a more corrective one is 
made. 

If such a jacket is worn by a patient who is making good 
progress, in a few weeks from the beginning of treatment it will be 
found to be inefficient and no longer to be holding him on account of 
his improvement. Under these conditions the original torso must be 
again remodeled, more cut away from the prominent side and greater 






Fig. 136. Fig. 137. 

Fig. i36.-^Remodeled Torso Ready for Application of Jacket. 
In a case of right dorsal left lumbar scoliosis which has been cut in two at the waist and 
set apart one inch so as to increase the upward pressure on the ribs. The dark areas on the 
left of the torso show where plaster has been added on the concave side to allow for cor- 
rection of displacement and deviation. — ("J. Am. Med. Ass'n.") 

Fig. 137. — Front of Jacket, made over Torso Shown in Fig. 136. Note Shoulder 
Pad. — ("J. Am. Med. Ass'n.") 

pressure exerted. In the course of a year, probably two or three 
such remodelings would be required. If the change in figure has 
been very marked, it will be better to make a new torso, rather than 
to attempt remodeling of the old one. If preferred these jackets may 
be made of leather or celluloid instead of plaster; but the plaster is 
perfectly efficient, although heavier. So long as frequent changes 
of jackets are necessary, plaster rather than leather jackets are to 
be advised. 

Mechanical Objections to All Corrective Jackets. — In applying 
force to correct the lateral curve and rotation of the scoliotic spine we 



176 TREATMENT 

cannot apply such force directly to the spine, but we must apply the 
corrective pressure to the ribs. The ribs are loosely attached to the 
spine, and are, moreover, rather easily distorted themselves by pres- 
sure. We, therefore, must do without that direct application of 
force to the affected structure which we possess in the treatment of 
most deformities.' 




Fig. 138. — Fenestrated Jacket for Right Dorsal Curve. As seen from the back. 

Secondly, to exert effective side pressure one must be able to 
press laterally not only against the apex of the lateral curve, but to 
exert counterpressure in the other direction at the top and bottom 
of the curve, ^ and this we cannot do by pressure against the thorax 
in high dorsal curves because we cannot reach as high as the top 
of the curve. To attempt to secure a higher level of side counter- 
pressure against the root of the neck is to pull against soft structures 
overlying a nerve plexus, where strong pressure is not tolerated, nor 
can heavy side pressure be exerted on the lumbar spine, conse- 
quently corrective jackets alone are not satisfactory in curves whose 
apex is as high as the upper dorsal region. In lower dorsal and 
dorsolumbar curves they find their best application. 

^ F. Lange: "Zentrlblt. fiir chir. and mech. orth.," Bd. v. Hft. 12. 



FORCIBLE JACKETS 



177 



Thirdly, forcible jackets, by fixation and pressure, cause atrophy 
of the muscles of the trunk and spine, and this fact has been much 
insisted upon by the opponents of the method. But when the time 




Fig. 139. — Fenestrated Jacket for Right Dorsal Curve, Applied. 

has corne to begin the after-treatment, such atrophy is quickly re- 
covered from by the use of gymnastics and massage, and by the 
gradual rather than the sudden discontinuance of the support when 
the proper time comes. 

That such jackets will prove detrimental to the general health 
is a fear which is not supported by facts, for the improved posture 
and the restoration of the viscera to a more normal position are 
more than enough to counterbalance the discomfort and the handi- 
cap of the jacket, in the great majority of cases. A gain in flesh 
and improvement in the general condition may, as a rule, be pre- 
dicted from the application of a proper jacket. In rare cases, 
12 



1 78 TREATMENT 

however, the wearing of plaster jackets results in deterioration of 
the general health, loss of flesh, and impaired digestion; and in such 
cases the surgeon will be obliged to act on his best judgment and 
often may be able to resort to treatment by gymnastics, combined 
with recumbency for several hours a day, returning gradually to 
the jacket when the condition improves. 




Fig. 140. — Radiogram of Case I before Treatment by Jackets was Begun. 

Finally, the danger to life during the application of jackets may 
practically be disregarded. Alarming symiptoms have arisen and 
in a few instances deaths have occurred as a result, but in these 
cases the use of force has been too great. With the use of judgment 
and moderate force no real danger can be incurred in normal 
individuals. 



RESULTS 179 

Curves due to congenital defects, infantile paralysis, rickets, and 
empyema are available for forcible correction; those from infantile 
paralysis being in their results often among the most satisfactory 
of all classes of moderate and severe scoliosis. 




Fig. 141- — Radiogram of Case I after Treatment by Jackets as Described. 

Results. — The author's point of view with regard to results to be 
obtained has been stated under prognosis (page 129) but to make the 
matter more definite the personal experience of the author in a 
group of test cases is here given with a view of placing on record the 
x-rays of a set of cases carefully observed and personally treated. 

Six cases were selected from the Scoliosis Clinic of the Children's 
Hospital for treatment in the fall of 19 14 and the photographs and 
x-rays of these cases were made under the supervision of the Scoliosis 



l8o TREATMENT 

Committee of the American Orthopedic Association in October. In 
the foU owing April these same cases were again presented to this 
Committee and their records again taken by them. These cases 
were under the personal treatment of the writer by whom all jackets 



Fig. 142. — Radiogram of Case II before Treatment by Permaxext Plaster 

Jackets. 

were applied. When it seemed advisable they were kept in the 
hospital for longer or shorter periods. Three of these cases are 
here presented. 

Case I. — Boy, five years old. Colored. Rachitic scoliosis, pre- 
viously treated by exercises. Right dorsal left lumbar curvature. 
Treatment was begun Nov. 2t^, 19 14, and ended in April. Four 
permanent jackets were applied. The patient is still under treat- 
ment by a removable jacket and exercises (Figs. 140, 141). 



RESULTS l8l 



Case 2. — Girl, eight years old, scoliosis due to infantile paralysis. 
Deformity noted in 1910. Curve, left cervicodorsal, right dorsal, 
left dorsolumbar. First jacket Oct. 29, 1914. Five permanent 
plaster jackets (Figs. 142-143). 




Fig. 143. — Radiogram of Case II after Treatment by Permanent Plaster 

Jackets. 



Case 3. — Boy, eight years old, etiology not determined. Curve 
left dorsolumbar. First jacket Nov. 9, 1914. Four permanent 
plaster jackets (Figs. 144-145). 

As the study concerned itself wholly with changes in the spine and 
not with changes in body outline only .v-rays are presented, the 
photographs being omitted, which show on the whole much more 



l82 



TREATMENT 



correction than is indicated by the x-rays. The x-rays were taken 
by the method of Bucholz and Osgood.^ 

Another case is given showing both x-rays and photographs to 
make clear the point that great change in body outHne may be 




Fig. 144. — Radiogram of Case III before Treatment by Permanent Plaster 

Jackets. 



secured without much alteration in the spinal curve as shown in 
the x-rays (Figs. 148-149). 

Case 4. — Girl, six years old, curve due to rickets, deformity noticed 
when two years old. Left dorsolumbar curve treated by jackets 
since May, 191 1. First photograph Oct., 191 1, second, April, 1915. 
Contemporaneous x-rays showing that while the photograph shows 

1 "Am. Journ. of Orth. Surgery," 1914, xii, 77. 



RESULTS 



183 



much improvement, the spine itself has been nearly stationary. 
(Figs. 146-147-148-149.) 

Permanence of Results. — Successful permanent results can be ob- 
tained in hospital practice only in selected cases, the average patient 
being unable to appreciate the importance of following out the treat- 
ment sufficiently long. The criticism that such correction is not 




Fig. 14s. — Radiogram of Case III after Treatment by Perm.\nent Plaster 

Jackets. 



likely to be permanent at once presents itself. The grounds that 
lead one to suppose that retention of the growing spine in a corrected 
position over a sufficient period will lead to a change in the shape of 
the bones of the vertebral column and to a permanently improved 
position are as follows : 



1 84 



TREATMENT 



(i) Club-foot may be cured by a similar proceeding. 

(2) The bones of the feet of Chinese women of rank are seriously 
misshapen by retention in an unnatural position.^ 

(3) WuUstein produced bony changes in dogs by a few months of 
abnormal position. 

(4) Arbuthnot Lane^ has demonstrated that the carrying of heavy 
loads by laborers will produce changes in the bony skeleton, and that 




Fig. 146. — Case IV before Treatment 
BY Plaster Jackets. 



Fig. 



147. — Case IV after Treatment 
BY Plaster Jackets. 



the changes vary according to the habitual position of the load, the 
bones subject to the greatest pressure undergoing changes in shape. 

(5) The fact that bone under pressure changes shape after growth 
has been reached is shown in the fact that scar tissue pressing on bone 
will cause a change in shape, ^ e.g., on the chin. 

(6) Pressure of tumors or aneurysm will cause absorption of bone. 
These facts all point to the conclusion that bone alters its shape 

1 P. Brown: "Jour. Med. Research," Dec, 1903. 

2 Guy's Hosp. Rep., xxviii. 



Ziegler: Pathology, English ed., 



), ii, 146. 



CHOICE or METHODS 1 85 

under changed conditions of pressure, and that although this would 
be more marked during growth, the phenomenon is not unknown in 
adult life. 

It seems reasonable to hope that the maintenance of improved 
position may be expected in time to produce a change in the shape 




Fig. 148. — Radiogram of Case IV before Treatment by Permanent Plaster 

Jackets. 

of the vertebrae. It is obvious that such a corrected position must 
be maintained over a period of many months to secure permanent 
results. Schanz^ has provided clinical evidence that his results have 
been permanent in the time during which thev were observed. 
Choice of Methods. — The choice between the use of fixed or re- 

^ " Verhdlg. d. Deutsch. Ges. f. orth. Chir.," iqo8, page 57. 



1 86 TREATMENT 

movable corrective jackets must be determined by the circum- 
stances of the patient, the temperament of the child, and similar 
considerations. Careless hospital patients will do better in a fixed 
jacket for a year or two, while nervous girls in private practice will do 
better in split jackets. 




Fig. 149. — Radiogram of Case IV after Treatment by Permanent Plaster 

Jackets. 

Gymnastics Following Forcible Correction. — So soon as the final 
corrective jacket has been removed and replaced by a removable 
one, gymnastic treatment should be begun. The exercises to be used 
have been described in the section on Gymnastics. Such treatment 
to accomplish results must be given from one to four hours a day for 
a period of at least six months from the removal of the final corrective 



GYMNASTICS 1 87 

jacket, after which less frequent and vigorous exercises may be suffi- 
cient. Exercises must be continued until the corrected position is 
maintained without apparatus from month to month, and the 
supporting apparatus discontinued at first for short periods, gradu- 
ally increasing in length. The length of time that active treatment 
must be continued will depend on the age of the child, the severity 
of the case, the efficiency of the treatment, and similar factors, but 
any case of scoliosis severe enough to require forcible correction will 
not, as a rule, occupy less than two years, and often a longer period. 
One cause of failure of efficient treatment hes in the unwillingness 
of^the parents or the patient to submit to sufficiently long-continued 
and effective treatment to remedy a condition which, if given the 
slightest consideration, can be seen to be one which is necessarily 
difficult and resistant. 



Fig. 150. — Swinging Head Piece for High Dorsal Scoliosis. 

Treatment of Cervico-dorsal and High Dorsal Scoliosis. — This type 
of scoliosis presents a special problem, not covered by what has 
preceded, for in so high a curve the plaster jacket cannot make 
effective side pressure above the apex of the curve because the latter 
is so high. In Chapter II it was noted that effective side pressure 
by a jacket could not be effectively made above the 4th or 5th rib. 
As a result of this, although in such curves it may be possible to 
press on the apex without counter-pressure at the upper end of the 
curve, corrective pressure cannot be obtained. Consequently one 
must abandon the idea of controlling this class of cases by a simple 
plaster jacket without a head-piece. 

The apparatus used by the writer has proved etfeclive in control- 
ling the upper part of the curve by upward traction on the head. A 



1 88 TREATMENT 

suspension jacket is put on just as in the lower curves and is carried 
as high as it will comfortably go. A Taylor head-piece, similar to 
that used in Pott's disease, is then made from a cast, embracing the 
chin and occiput. This cast is taken with plaster of Paris bandages, 
which are wound circularly around the head and occiput, then 
removed and filled. 





Fig. 151. — "Minerva" Jacket 
Used by Calve in Correction of 
High Dorsal Scoliosis. Seen 
from the front. (Calve) 



Fig. 152. — ''Minerva" Jacket Used 
BY Calve in Correction of High 
Dorsal Scoliosis. Seen from the 
back. (Calve) 



The head-piece is fastened at the back to a piece of steel through 
which an upright hole has been bored, and this upright hole sets down 
on a post which fastens to the jacket by means of two boxes attached 
to steel uprights on the back of the jacket. The post is raised and 
lowered by a rachet and pinion action, a set of teeth being cut in the 
posterior part of the post. It is raised and lowered by a key and a 
band slips down when the proper position has been reached, holding 
the position by means of a spring with a projection on the front 
which fits into the space between the teeth. Fig. 150. 

In the old form of the apparatus, the post was the only connection 
between the jacket and the head-piece, but this allowed only hori- 
zontal motion of the head and made studying very difficult. The 



OPERATIVE TREATMENT 1 89 

apparatus was then modified by having the post attached to a yoke 
running half way forward on both sides of the base of the skull and 
the yoke was joined to the head-piece just under the ear, allowing 
antero-posterior motion also. This does not diminish the efficiency 
of the apparatus and allows flexion and extension of the head as 
well as rotation. 

This apparatus is used in connection with exercise treatment by 
being mounted on a removable jacket and being kept at a constant 
height, making slight traction on the neck two or three times a 
day by winding it up as far as the patient can stand it and leaving it 
there for a minute or so, making a real traction on the curve. With 
the use of this apparatus a very different grade of result has been 
obtained from that which was previously possible. 

The same point of view is held by Calve, who meets the situation 
by the use of a plaster jacket, cut away on the hollow side, and 
supporting the head. This he speaks of as the Minerva, which he 
uses in high dorsal scoliosis. 

OPERATIVE TREATMENT OF SCOLIOSIS 

The earlier operations for the relief of scoliosis have been given up. 
Resection of the ribs on the convex side of the curve as proposed by 
Volkmann^ and Shaffer ^ and carried out by Casse^ and Hoffa,^ 
and an operative correction by Hoke,^ who also lengthened the ribs 
on the concave side, and somewhat similar operations by Jaboulay^ 
and Bade^ have not been satisfactory. 

The question of stiffening the spine in the region of the curve has 
of late been much discussed and is being practised on a large scale in 
certain localities. The operations in vogue are the Hibbs operation 
in which the spine is cut down on, the laminae and spinous processes 
are exposed, the periosteum is stripped in an incomplete tube from 
the laminae out as far as the transverse processes; the spinous proc- 
esses are then cut part way through and broken down and the 
edges are cut through and broken down while the edges of the 

^Volkmann: "Berl. klin. Wochens.," 1889, 50. 

2 Shaffer: "Amer. Surg. Bulletin, "Jan. i, 1894. 

3 Casse: Bull, de I'Acad. Royalde Med. de Belgique.," Dec. 30, 1893; Jan. 27, 

1894. 
^Hoffa: "Zeitsch. f. orth. Chir., "1896, 401. 
^Hoke: "Amer. Jour, of Orth. Surg., i, 2. 
^Jaboulay: "Prog. Med.," Nov., 1893. 
''Bade: "Klin Mittheil. in Centrabl. f. Chir.," 1903, 38, 1045. 



igo 



TREATMENT 



laminae are refreshed. The tube of periosteum is then brought to- 
gether and closed in the middle line and the skin sutured. The spine 
is pressed into the best possible position and the jacket applied. 





Fig. 153- — Boy Aged 12, before Treat- 
ment. — {"J. Am. Med. Assoo.") 



Fig. 154. — Boy Aged 14, after Two 
Years' Treatment by Means of Per- 
manent Jackets (See Fig. 153). 



The other operation is the Albee operation in which the spine is 
cut down on, the spinous processes split vertically down nearly to 
the canal, and a bone graft from the tibia, or a piece of beef bone, 
is put into the cleft after being properly shaped, and is held in 
place by kangaroo tendon sutures. The after treatment is the 
same as in the operation just described. 

There is no question that this induces ankylosis of the posterior 
part of the spine in the region operated on, but the operation is too 
recent to enable us to determine what the ultimate results are going 
to be. The objection to the operation is that it is not effective on 
the bodies, but on the laminae or spinous processes and this leaves 
the bodies free to rotate as the patient grows while the posterior part 
of the spinal column is held stiffly by the ankylosis. In certain cases 
a very marked increase of rotation has occurred soon after the 
performance of the operation, and although a good many reports of 



OPERATIVE TREATMENT 



191 



groups of cases, seemingly favorable, have been made, the value 
or the danger of the operation cannot be fairly estirnated until 
several years of growth have passed, permitting us to judge of the 
results of fixing the spine posterior to its center of rotation. 

The present discredit of gymnastic retentive treatment is due to its 
use in too small dosage and to a failure to appreciate that a problem 
so grave as the permanent maintenance of the corrected position 
in a spine, which has suffered some degree of bony distortion, is 
only to be obtained by a long continuance of accurate and mechan- 
ically sound treatment. 




Fig. 155. — Girl Aged 16, before Treatmeni.— (,•/. Am. Med. Ass'n.") 

Finally it should be borne in mind that certain cases of severe 
scoliosis^ in young children, particularly when due to congenital 
defects in the vertebrae, and very severe scoliosis in children in middle 
childhood can be best treated by recumbency. In this way the 
weight of the body is changed from being a detrimental influence to 

^ Gaudier and Swynghedauw: Rev. d'orth. 1921, viii, 270. 



192 



TREATMENT 



being a helpful one. Also in certain cases it will be evident to the 
surgeon that if the parents can be induced to adopt it, recumbency 
in a well-fitting jacket or on a posterior plaster shell will prove far 
more efficient than any ambulatory treatment. 




Fig 156. — Girl Aged 18 after Two and a Half Years' Treatment by a Series of 
Permanent Corrective Jackets. See Fig. 155. — ('V. Am. Med. Assn.") 



OPERATIVE TREATMENT 



193 




Fig. 157. 



Fig. 158. 



Fig. 159. 




Fig. 160 Fig x6i. 

Figs. 157-161. — History of a Case of Scoliosis from 1903-1910. 
^IGS. 157. 158. — 1903-5. Increase under gymnastics and imperfect jacket treatment. 
Figs. 158, 159. — 1905-7. Treatment by jackets (one forcible ) and gymnastics. 
Figs. iS9. 160. — 1907-9- Left clinic and had gymnastics twice a week outside with no 
jacket. 

Figs. 160, 161. — 1909-10. Returned to clinic but heart displacement was so great that 
only a mild brace was possible with no gymnastics. 
13 



CHAPTER XIV 
FAULTY ATTITUDE 

xor:^i.\l attitude 

In addition to curves to the side in the spinal column, which have 
been described as scoliosis, there are modifications of the normal 
forward and backward spinal curves which demand consideration. 
Although it is comparatively easy to say whether or not a patient is 
normally symmetrical when seen from the back it is not so easy to say 
whether or not a given attitude as seen from the side is normal, 
because there is no properly established normal attitude in the stand- 
ing human figure as seen from the side. It is necessary first to 
consider those facts which are known with regard to the normal 
attitude before passing on to analyze its abnormalities. Normals 
have been described by Weber, Meyer, Langer, Parow, Henke, 
Staff el and others, which difi'er much among themselves as would 
have been expected, from the lack of a uniform or satisfactory system 
of measurement and also because the standing position is influenced 
by sex, age, race and occupation. 

As the problem is one of balance from the feet up, it is evident that 
any reliable method of analysis must take into account the base of 
support and the line of gravity in order correctly to represent the 
normal balance of the body in the standing position as seen from the 
side. Merely to draw an outline of the body and construct an ideal 
figure without regard to the relation of such spinal curve to the 
legs or line of gravity is not reliable. One has only to read the 
appended literature to realize that we have no reliable normal of 
the standing position as seen from the side.^ 

^ Borellius, J. A.: "De Motu Animalium, Lugduni Batavorum,'' 1679. 
Braune, W., and Fischer: " Ueber den Schwerpunkt d^s menschlichen Korpers, 
Abhandl. d. k. Sachs.," "Akad. d. Wissensch., ZMath.-ph^-sik Klasse,'' Leipsic, 

1899, XV, 7. 

Dickinson, R. L.: ''The Corset; Questions of Pressure and Displacement," 
"New York Med. Jour.," Nov. 5, 1887. 

Duchenne : '' Etude ph3'siologique sur la courbure lombo-sacree et de I'inclina- 
tion du bassin pendant la station verticale," "Arch. gen. de med.," series 6, \'iii, 

534- 

Goldthwaite, J. E. : "The Influence of Pelvic Joints on Posture," "Physical 
Education Rev.," June, 1909. 

194 



ANALYSIS OF UPRIGHT POSITION 1 95 

A new method of record which promises to enable one to analyze 
the normal standing position and its abnormalities is that of Rey- 
nolds and Lovett/ but until a large number of normal studies have 
been made, no reliable statement of what the normal really is, can 
be made, and no very accurate information can yet be given of 
variations from the normal in this plane. This method gives a side 
elevation of the erect standing position of the individual, with at 
the same time, the position of the line of gravity in its relation to 
the body and to the base of support. The method is as follows: 

On the platform of a dial scale registering up to loo pounds is placed a sharp 
edge which supports one end of a flat board (B), the other end of which is sup- 
ported by a similar sharp edge placed on a rigid block (C). The distance 

Goldthwaite; "The Relation of Posture to Human Efficiency," Boston: 
"Med. and Surg. Journal," Dec. 9, 1909. 

Gerdy: "Determination des levriers que forment la colonne vertebrale, les 
femurs et les tibias dans I'attitude verticale," "Rev. med.," 1834, 323. 

Horner, F.: "Ueber die Kriimmung der Wirbelsaiile im aufrechten Stehen," 
"Inaug. Diss. Zurich," 1854. 

Kellogg, J. H.: "Experimental Researches; Relation of Dress to Pelvic Dis- 
eases of Women," "Tr. Mich. State Med. Soc," 1888. 

Kellogg, J. H. : " The Relation of Static Disturbances of the Abdominal Viscera 
to Displacements of the Pelvic Organs," "Proc. Internat. Periodical Cong. 
Gynec. and Obstet.," 1892. 

Kohlrausch, E.: "Physik des Turnens Hof.," 1887, page 17. 

Lane, W. Arbuthnot: "Lancet," London, Nov. 13, 1909. 

Meyer, G. H.: "Die Statik und Mechanik des menschlichen Knochenge- 
riistes," Leipsic, 1873. 

Mosher, Eliza M.: "The Influence of Habitual Posture on the Symmetry and 
Health of the Body," "Brooklyn Med. Jour.," July, 1892. 

Mosso: "Application de la balance a I'etude de la circulation chez I'homme," 
"Arch. ital. de bioL," 1884, v. 131. 

Parrow, W. : "Studien iiber die physikalischen Bedingungen der aufrechten 
Stellung und der normalen Kriimmungen der Wirbelsaiile," "Virchows Arch. f. 
path. Anat.," 1864, xxxi, 74, 

Schmidt: "Unsere Korper," 1903, page 6^. 

Staffel, F. M.: "Die menschlichen Haltungstypen und ihre Beziehung zu den 
Riickengratsverkriimmungen," Wiesbaden, 1889. 

Taylor, C. Fayette: "Spinal Irritation, or the Causes of Backache among 
American Women," New York, William Wood and Co., 1870; "Tr. Med. Soc, 
New York,"i864. 

Weber, M, and E.: "Mechanik der menschlichen Gewerkzeuge," Gottingen, 
1836. 

^ Reynolds, E., and Lovett, R. W.: "ISIethod of Determining the Position of 
the Center of Gravity in Its Relation to Certain Bony Landmarks in the Erect 
Position," "Am. Jour. Physiol.," May i, 1009; "Jour. Am. Med. Assn.," ^lar. 
26, 1910. 



196 



FAULTY ATTITUDE 



between the edges is 508 mm. (20 inches). A short distance behind the rigid block 
is placed an upright post (E) with a horizontal sliding arm (D, shown in section 
only), which furnishes a plane of reference from which the antero-posterior 
position of each of the important landmarks of the body can be determined by 
measuring their horizontal distance from this sliding arm (Fig. 162). 
• The determination of the antero-posterior position of the center of gravity 
in the standing subject is made as follows: 

The subject is weighed on an ordinary set of scales. He is then placed on thfe 
balance plane (B) at a known point facing the scales. (The exact point is un- 
important, but after experimentation there was selected as most convenient that 
in which the heels are situated at one-fourth the length of the plane from the 
posterior sharp edge.) A removable ledge (F) against which the heels are placed 
is provided here. 

Since the balance plane on which the subject stands acts as a lever, in which 
the weight is borne between the fulcrum (the posterior sharp edge) and the sup- 
porting force (the spring which governs the scales), it is evident that the weight 
recorded on the dial (the balanced weight) will bear to the total weight the same 
proportion as that which obtains between the total length of the balance plane 
and the distance between the perpendicular dropped from the patient's center 
of gravity and the posterior end of the plane. That is : As the total weight is to 



^ 




-^ 



-Br 



Wu 



D 



Fig. 162. — Diagram of the Apparatus for Estimating the Center of Gravity. 

A, scale; B, balance plane on which patient stands facing A; C, block supporting triangular 
edge; D, movable horizontal arm on upright for obtaining horizontal distances; E, vertical 
upright for standard plane; F, ledge against which heels are placed. — {^"American Journal 
of Physiology.") 



the balanced weight, so is the total length of the board to the horizontal distance 
of the center of gravity of the patient from the posterior sharp edge (the ful- 
crum), or, to illustrate by a specific instance: The subject's total weight is 140 
pounds; when placed on the balance plane his weight is 50 pounds, and the total 
length of the board is 20 inches. 



NORMAL ATTITUDE 



197 



The formula reads then; 

140 _ 20 
50 ~ X 
This is then worked out as follows: 

140)1000(7.1 
980 
200 
The center of gravity of the subject then lies perpendicularly above a point 
7.1 inches forward from the posterior sharp edge. 




Fig. 163. — Apparatus in Use. The Lines Drawn Represent the Lines Shown in 
THE Record Tracings. The Long Line Running Vertically is the Perpend cvlar oi- 
THE Center of Gravity. — {"J. Am. Med. Ass'v.") 



FAULTY ATTITUDE 



After the determination of the position of the center of gravity, which should 
occupy on an average one or two minutes, the position of the following points 
which have been marked on the skin are measured and recorded. 

1. The position of the back edge of the malleolus.^ 

2. The position of the back of the head of the fibula. 

3. The position of the middle of the trochanter 

4. The position of the posterior part of the spine of the fifth lumbar vertebra. 

5. The position of the posterior part of the spine of 
the seventh cervical vertebra. 

All these points are taken under the usual conventions 
of somatologic measurements on the living. 

The measurements having been recorded, are then 
easily translated into graphic form by the reproduction 
of the observed measurements on a sheet of paper, of 
which the bottom represents the balance plane and the 
edge of the paper the posterior plane of measurement. 

These five comprise all the exact measurements which 
are taken, but since the value of their graphic representa- 
tion is considerably enhanced by its combination with 
some sort of representation of the body profile of the 
indi\ddual, we have completed the examination by the 
use of a device which obtains this with fair accuracy 
and which is illustrated in Fig. 163. 

A series of horizontal metal arms, tipped with cellu- 
loid, slide easily through holes in the vertical wooden 
arm. These metal arms are shaken out to their full 
length, and their ends pushed rapidly and lightly against 
the subject's back in the median line, the point of the 
uppermost horizontal arm being applied to the seventh 
cervical vertebra. In the construction of the graphic 
record (Fig. 170), the position of this profile is known by 
its relation to the seventh cervical and fifth lumbar 
vertebrae; that is, these points are marked on the paper 
from the measurements taken, and the end of the upper- 
most arm of the profile instrument is laid against the 
mark which represents the seventh cervical, while a lower 
point is in contact with the mark representing the fifth 
lumbar vertebra. The curve is then traced on the paper^ 
containing the other measurements from the ends of the 
pins throughout its length. 
The body curve of the ventral surface is obtained in the same way. The upper- 
most arm of the profile instrument is applied to the anterior surface of the neck at 



Fig. 164. — Record 
OF THE Normal Posi- 
tion AND THAT 

Induced by High- 
heeled Shoes, the 
Normal in Solid 
Line, the Induced 
Position in Dotted 
Line. — ("/. Am. Med. 
Ass'n.") 



^ In this and the following determinations the horizontal difference is obtained 
by a footrule, one end of which is placed against the marked point, while the body 
of the rule is held by the thumb against the upper surface of the sliding arm. 
Since this surface (and therefore necessarily the rule) is horizontal, the height of 
the point observed may be read at the same time, from a graduated scale which 
is marked on the upright post. 



NORMAL ATTITUDE 1 99 

the level of the seventh cervical vertebra. The position of this curve on the 
chart is ascertained by using as points of reference the horizontal distances 
between the posterior parts of the seventh cervical and fifth lumbar vertebrae 
and the points horizontally opposite on the ventral surface, measured on the 
subject by a pelvimeter or other calipers. 

It would be very desirable that this graphic record should be completed in 
every instance by a representation of the inclination of the brim of the pelvis, 
which would, of course, include its relation to the trochanter, but after much 
experimentation we have been unable to measure with accuracy the inclination 
of the pelvic brim in the living subject. 

The use of the profile curves in the graphic representation involves the dis- 
advantage that the chart must be drawn life-size, but it can be reduced later by a 
pantograph to any desired size. 

The sources of error; incident to the method are swaying of the subject, errors 
in measurement from the vertical plane, distortion of attitude during observation, 
inaccuracy in locating on the skin the bony landmarks selected, varying position 
of the feet, horizontal rotation of the pelvis and psychical influences. These 
errors and their prevention are dealt with at some length in the original descrip- 
tion of the method. 

So far as the observations by this method have gone they show 
that in the erect position the center of gravity of the body lies in 
front of the ankle-joints, which are held from dorsal flexion in this 
position by the gastrocnemius muscles. The center of gravity lies also 
in front of the knees, which are held in position by the ham- 
string and quadriceps extensor muscles. The center of gravity 
lies also anterior to the sacro-iliac joints and most of the vertebral 
joints. The position of the acetabula cannot be determined in the 
erect position in the living individual because we have no means 
of locating them from any available landmarks. If we were able 
to determine the position of the acetabula in the antero-posterior 
plane it would be possible to state definitely, from the relation of 
the center of gravity to them, whether the trunk in the erect position 
would tend to fall forward or backward at their level. But from 
the impossibility of obtaining definite data on this point we are 
obliged to resort to another line of observations to determine this 
matter. 

It has been shown by many experiments that when the cadaver is 
stood erect and the legs and ankles are fixed (to prevent the cadaver 
from collapsing on the ground), the trunk falls forward from the hips. 
In the erect position then, the trunk is held extended on the legs by 
the combined and continued action of the posterior musculature, the 
chief factors here being the hamstrings, the glutei and the erector 
spinfe muscles. 



200 -FAULTY ATTITUDE 

After a consideration of this theoretical side of the subject which 
will in time enable us to obtain exact information as to abnormalities 
of the standing position it becomes necessary to formulate our 
present knowledge with regard to these abnormalities. 

When the antero-posterior and lateral variations coexist, as 
frequently happens, the lateral variation is in general considered the 
more important one, and the case is classed as scoliosis. 

ROUND SHOULDERS 

Stoop or slant shoulders, round back, round hollow back, stoop- 
ing, faulty attitude, kyphosis, bowed back. 

German — Schlechte Haltung, runde Riicken, K3rphose, hohlrunde 
Riicken, kypholordose, habituelle Kyphose. 

French — ^Dos Voute, Cyphose. 

Italian — Schiene rotonde. ' ' 

Grouped under these names are various types of faulty attitude, 
but variations from the normal antero-posterior attitude are in 
general grouped under the name of round shoulders. These shade 
into each other and are characterized by a disposition to economize 
muscular force in maintaining the erect position, an increased con- 
vexity of the dorsal spine being the most common characteristic. 

In general the attitude is familiar, the head is carried forward and 
is somewhat flexed, the physiological curve in the dorsal region is 
increased so that the dorsal region is unduly prominent behind, in 
which backward curve the lumbar region may also share, or there 
may be in place of this an increased lumbar curve forward. The 
shoulders are drooping and the chest narrow and flat, while the 
posterior borders of the scapulae are prominent and the inferior 
angles may project markedly (scapulae alatae). The abdomen is 
prominent especially in its lower part. Flat-foot or pronated foot 
frequently coexists. 

Children with round shoulders are, as a rule, below the average in 
muscular development and lack vigor; they are clumsy in their 
movements and walk heavily. The attitude described, with round 
back, flat chest and relaxed abdomen, is beyond all question most 
undesirable from the point of view of appearance, efficiency and good 
health. It means diminished inspiratory capacity, more than normal 
muscular effort in standing and walking, and it should predispose to 
ptosis. 

Its relation to ptosis has received particular emphasis. It would 



ROUND SHOULDERS 



20I 



seem as if the attitude in children would predispose to dropping of 
the intestines and stomach, but in 83 cases investigated by Sever ^ 
of normal children whose development was investigated by Bismuth 
:j:-ray, the general position of the stomach was much lower than is 
generally recognized, and it was not at all unusual to find the stomach 




Fig. 165. — Round Back with Flat Chest and Prominent Abdomen. 



at or below the crest of the ilium; yet only one of these children had 
any symptoms which could be attributed to ptosis, chronic consti- 
pation existing in this case. It cannot, therefore, be assumed in 
view of this evidence that ptosis is caused by the attitude of round 
shoulders, inasmuch as the majority of normal children showed a 
position of the stomach which would have been recognized as 
1 Sever, New York Med. Journal, Sept. 20. 191Q. 



202 



FAULTY ATTITUDE 



ptosis. That adult ptosis is a frequent cause of arthritis, auto-intox- 
ication, low vitality, poor general resistance, pulmonary tuberculosis, 
impaired digestion, loss of flesh, constipation, abdominal pain, and 
similar conditions is not to be disputed. That faulty attitude in 
children is undesirable is recognized, but that faulty attitude in 
children is accompanied by an unusual degree of ptosis over the nor- 
mal for that age, is not established. ^Marked faulty attitude with 
a prominent abdomen in adults is likely to indicate ptosis, and is 




Fig. i66. — Round Back. 

not only unsightly, but detrimental, and should be remedied; however 
it must not be forgotten that in both children and adults the faulty, 
slack standing position is at times the result rather than the cause 
of the ill health. We are sometimes inclined to confuse cause and 
effect in this connection. 

In some cases the deformity can be removed by a muscular effort 
on the part of the patient or by gentle pressure with the hands, but 
in most cases of even average severity the deformity cannot be wholly 
corrected by gentle passive force, as the maintenance of the malposi- 



ROUND BACK 203 

tion has led to adaptive shortening of the soft parts concerned. 
The cases may, therefore, be considered as (i) flexible or (2) resistant, 
an important distinction in treatment. Great injustice is done to 
children with resistant round shoulders by the continual commands 
to "sit straight," a position which it is impossible for them to 
assume. 

If such a child is laid face downward on a table with the arms at 
right angles to the body the arms may by passive force be carried 
back of the middle line of the body. If in this position the arms are 
carried up beside the head and then lifted back they cannot as a rule 
be carried so far as the median plane of the body. If such a child 
is told to put the arms up in the air in the standing position, it 
is done by making the back hollow in the lower part and protruding 
the abdomen, because the soft parts between the chest and arms 
have become contracted and do not permit a free movement.^ 
Lateral curvature of the spine frequently coexists. 

The affection is not wholly one of the spine, but implies a disturb- 
ance of relations from the feet upward because an increase in the 
backward curve of the spine implies a forward curve or forward dis- 
placement somewhere else to balance it. The dorsal spine in other 
words cannot become more convex without a compensating lumbar 
curve forward, or a forward displacement of the pelvis and legs if the 
lumbar spine is involved in the backward dorsal curve. 

Round shoulders, therefore, is not to be considered or treated as 
an affair wholly concerning the dorsal spine and shoulders. On 
closer analysis these cases will be found to fall into four not very well- 
defined groups. Transition cases of all grades are seen, and the 
division is mentioned simply to aid in the study of the cases and their 
treatment. The groups are as follows: 

I. Round Back. — The dorsal and lumbar spine form one convexity 
backward, which is physiologically a persistence of the infantile 
position (page 21). A lordosis is apparently often present on inspec- 
tion, but on identifying the landmarks offered by the spinous proc- 
esses of the vertebrae this will be found to be merely the upward and 
forward slope of the sacrum and that the lumbar spine does not share 
in it. In counting the vertebrae it must be remembered that the 
spine of the fourth lumbar is as a rule on a level with the top of 
the iliac crests and that the first vertebra below this level will mark 
the end of the spine; nearly every one is likely on inspection to 

- E. H. Bradford: "Round Shoulders," " Orlh Trans." vol. x. jxiirc 10:. 



204 



FAULTY ATTITUDE 



estimate the lower end of the spine as coming down lower than 
it really does. 

2. Round Hollow Back.^-The dorsal spine is bowed backward, 
but the lumbar spine is bowed forward. The appearance of round 
shoulders is present, but the general attitude is modified because the 
pelvis apparently has a greater inclination than in round back, the 
abdomen is prominent, and the gross appearance is the same as in 
round back (Fig. 167). 







Fig. 167. — Round Hollow Back. 



Fig. 168. — Round Upper Back. 



3. Round Upper Back. — In certain cases the dorsal backward 
curve occurs in the upper part of the spine and gives an especially 
noticeable forward thrust to the head and a prominence between the 
scapulae. These cases are rather Hkely to be rigid and respiratory 
capacity is poor. The lumbar physiological curve is not necessarily 
abnormal (Fig. 168). 



ETIOLOGY 205 

4. Flat Back. — In certain cases, the vertebral column is' flat and 
has apparently nearly lost its dorsal and lumbar physiological curves. 
The pelvic inclination is obviously diminished and a frequent 
association with this attitude is a forward resistant position of the 
shoulders.^ This forward position of the shoulder girdle may, how-y 
ever, accompany other forms of antero-posterior deviation, such as 
round back. 

In certain cases as noted by Haglund^ the back is rounded from 
side to side without especial kyphosis. 

It must be recognized how very superficial and unsatisfactory this 
classification is and it must be evident that we are a long way from 
recognizing the essentials which cause this condition. For purposes 
of discussion these four divisions will still be spoken of as round 
shoulders in spite of the fact that this is merely one expression of 
faulty antero-posterior attitude which "involves the vv^hole body from 
the base of support to the head. 

ETIOLOGY 

The shape of the figure is as characteristic of the individual as the 
form of the features and some children inherit straighter spines than 
others. A certain amount of importance must therefore be attached 
to the type of spine with which the child starts. Further evidence 
of a congenital origin of round shoulders than this (except in gross 
congenital lesions of the spine), is on the whole wanting. 

In general the causes of round shoulders are to be sought in— (a) 
conditions causing muscular weakness; (b) conditions causing a flexed 
position of the spine for long periods, and in (c) overweighting of the 
shoulders by improperly arranged clothing; (d) rickets. Some 
German writers incline toward the view that a weakness of the will 
is a more important cause than weakness of the muscles. 

Conditions causing muscular weakness are found in rapid 
growth, overwork and bad air at school, improper school furniture,, 
acute illness, bad hygiene at home, and similar conditions. 

Prolonged flexion of the spine is induced by school furniture 
which fafls to support the back, by errors in vision which necessitate 
stooping over the books in reading, and in careless attitudes of read- 
ing and sitting permitted at home. The child with normal eyes 

^Hasebrook: "Zeitsch. f. orth. Chir.," xii, 4, 613. 
2Haglund: "Zcitsch. f. orth. Chir.," xxv, 649. 



2o6 



FAULTY ATTITUDE 



should not have to hold the book nearer than twelve to fourteen 
inches. 

The customary method of supporting a child's clothes in this 
community consists in the use of a waist, loose around the abdomen 
to which drawers and skirts or trousers are buttoned.^ To this waist 




Fig. 169. — Flat Back; Forward Position 
OF THJE Shoulder-girdle. 



Fig. 170. — Waist with Garters Pulling 
Shoulders Down and Forward. 



are also attached side elastic stocking supporters which are kept tight 
to prevent the stockings from wrinkling. This waist is supported 
above by two shoulder-straps passing over the shoulders near their 
tips. The whole weight of the clothes and the added pull of stout 
elastics is thus transferred to the child's movable shoulders, of all 
parts of the body the least suited to hold against a steady downward 
pull. This pull is transferred in a measure by the spine by the 
muscles, clavicles, and thorax, and tends to produce flexion of the 
dorsal spine as well as forward displacement of the scapulae and 
shoulder joints. 

1 Bradford: "Orth. Trans.," vol. x, 162: Goldthwait: "Amer. Jour, of Orth. 
Surg.," vol. i, 64. 



PATHOLOGY AND MECHANISM 207 

The remedy of this condition consists in supporting as much as 
possible the clothing from a belt, using round garters, or in cases 
with markedly prominent abdomens the use of the corset waist to 
be described. 



OCCURRENCE 

In examinations of school children the observers find exaggerated 
antcro-posterior curves less frequent than lateral curves, but as ex- 
plained before it is often impossible to say what an abnormally 
increased antero-posterior curve is and what is normal. 

At Stockholm, Haglund found, in 1599 children, 280 scolioses and 
170 antero-posterior curves (90 boys and 80 girls). 

The Lausanne series of 2314 children showed 571 scolioses (24.6 
per cent.) and 135 antero-posterior curves (5.8 per cent.), with 47 
combined cases included in the above. 

Gronberg found 715 antero-posterior curves in 8250 Finnish 
children. They were divided as follows according to his 
classification: 

Kyphosis (round back), 478 (66.9 per cent.). 

Kypho-lordosis (round hollow back), 149 (20.8 per cent.). 

Lordosis (hollow back), 88 (12.3 per cent.). 

The age of occurrence of round shoulders covers the period of 
childhood from shortly after the time that walking begins to adoles- 
cence; most cases are seen by the surgeon in middle childhood and 
about puberty, when in girls especial attention is paid to the figure 
and carriage. 



PATHOLOGY AND MECHANISISI 

The pathological changes in round shoulders must be determined 
rather by inference and interpretation of clinical symptoms than by 
postmortem examination. 

Permanent kyphosis in a healthy growing dog was produced ex- 
perimentally by Wullstein, who approximated the pelvis and 
shoulders by straps, causing a flexed position of the spine. In 
children who continue to grow with the spine in flexion, analogous 
adaptive changes must occur in the spine and its surrounding struc- 
tures to those found in scoliosis. The mechanism oi the flexible 



2o8 FAULTY ATTITUDE 

type requires nothing more than the presence of muscular weakness 
from fatigue or other conditions and the resultant assumption of the 
easiest attitude which is that of the slumped position. With the 
long continuance of this position the soft parts, muscles and liga- 
ments, become stretched* on one side and adaptively shortened on 
the other, and in the severer cases some change in the shape of the 
vertebral bodies may occur, because growing bone is plastic and 
the deformity thus becomes fixed, perhaps seriously so. Round 
shoulders cannot with impunity be allowed to remain untreated. 

As a result of the dorsal curve and the relaxed abdominal wall, 
chest function is impaired and chest capacity diminished; the 
abdominal organs are not supported in place and the vertical height of 
the abdomen is lessened. One would therefore look for a ptsois of 
the abdominal organs, but that this does not always coexist has 
been shown by Sever (see p. 201), ' 

Instead of attacking the round shoulders as the primary con- 
ditions, as we are so apt to do we should in children, especially, 
look and treat the cause of the round shoulders, which will very 
often be traceable to some cause affecting the general resistance. 



DIAGNOSIS 

The diagnosis of round shoulders, when it is present in any marked 
degree, as a rule, presents no difficulty, but at times it is not easily 
distinguished from more serious affections, causing a backward bow- 
ing of the spine. The means of distinguishing between the different 
varieties of round shoulders have been sufficiently indicated in the 
description of them. The important point is to distinguish a static 
bowing of the spine from one caused by disease. In the former there 
is no marked stiffness of the spine, pain is absent, the bowing is 
gradual, and x-ray appearances are normal. 

Differential Diagnosis. — PoWs disease (tuberculosis of the spine, 
angular curvature of the spine) was discussed in speaking of the diag- 
nosis of ■ scoHosis. At certain stages of dorsal Pott's disease the 
attitude may resemble round shoulders. Arthritis deformans of the 
spine was discussed under the diagnosis of scoHosis. 

No gymnastic treatment for a case of round shoulders should be 
undertaken in a patient where pain or stiffness of the back is present 
without a very careful preliminary period of observation and a 
careful ehmination of the first two conditions mentioned »above. 



TREATMENT 209 

PROGNOSIS 

The attitude of round shoulders is not to be regarded as one which 
will be spontaneously outgrown, it requires treatment, and with 
adequate treatment and proper hygiene the prognosis for recovery 
is good in young children. In older children and adolescents 
improvement and perhaps cure should be obtained. Even in young 
adults an improved position of the shoulders and a better expansion 
of the chest are to be secured by adequate treatment. 

If the attitude of round shoulders is allowed to persist into adult 
life there are certain respects in which it may affect unfavorably the 
health of the individual. The flat chest and- diminished chest 
capacity mean impaired respiratory capacity and increased suscepti- 
bility to pulmonary affections, diminished room for the heart, and 
the large abdomen favors ptosis of the abdominal viscera, both 
factors leading to impaired efi&ciency.^ Moreover, the bowed spine 
is generally a weak spine and such patients are liable to static back- 
ache, ^ that is, a backache due to strain of the posterior muscles 
described under the names of "hysterical spine," irritable spine," 
etc. 

TREATMENT 

The treatment of round shoulders is different in flexible or non- 
resistant cases and in resistant cases. 

Flexible Round Shoulders. — ^The treatment does not differ 
radically from that, of postural scoliosis in that both are of the type 
of the "setting-up drill" of the army recruit. In both, one tries to 
substitute a correct attitude for the incorrect or faulty one, but 
general flexibihty of the spine must be restored before the treatment 
can be fully effective. What has been said with regard to the 
treatment of postural or functional scohosis applies to the treatment 
of flexible round shoulders, the routine and exercises for both 
conditions being described below. 

Two types of exercises are given for this condition: i. Back; 
2. Abdominal. 

1 Goldthwait & Brown: "Am. Journ. of Orth. Surgery," Nov., 1911, 
Brown, L. T.: "Boston Med. & Surg. Jour., June 24, 1920. 
Brown, L. T.: Am. Jour. Med. Sc, Nov., 1920. 
Brown, L. T.: "Am. Jour. Orth. Surg., Nov., 191 7. 

• Goldthwait, J.: Surg. Gyn. & Obst., 1913, xvii, 587. 

* Reynolds and Lovett: ''Journ. Med. Assoc, TNIar. 26. loio. 

14 



2IO 



FAULTY ATTITUDE 



1. The patient stands and bends the body farward at the hips and 
flings the arms forward and upward with the elbows straight. A 
deep breath is taken as the arms are flung forward and it is important 
that the back be kept straight as the bending position is assumed. 

2. The patient Ues on his back and comes up to a sitting position, 
with the hands behind the neck, while the knees are held. 

Resistant Round Shoulders.^ — The treatment of these cases is 
similar in plan to that of structural scoliosis where first mobilizing 
and then retentive measures must be separately recognized, even 
if both are carried out simultaneouslv. 



t 




^1 


1 IT 





Fig. 



171. — Apparatus for Stretching Round Shoulders and for the Application of 
Forcible Jackets. 



The same developmental exercises are used as for flexible round 
shoulders, and in addition the following exercises to mobilize the 
spine: i. The patient while kneeling, arms stretched in front, 
and elbows straight, tries to touch the chest to the table, at the 
same time raising the head. This stretches the dorsal region and 
does not exaggerate the lumbar curve. 

2. The patient Hes on his back with a pillow rolled up under the 



TREATMENT 211 

shoulder blades. The lower ribs being held down by the operator, 
the patient attempts to bring both arms over the head and down to 
the table. 

When the lumbar spine is stiff in lordosis, it is of no use to mobihze 
the dorsal region unless the lumbar curve is also corrected, which 
may be accompHshed by means of the following exercise: 

3. Sitting, with the legs straight ahead, the patient attempts to 
put the head on the knees. 

Mobilization. — When the shoulders are held forward by contrac- 
tion of the soft parts and cannot easily be replaced in the normal 
position, simple gymnastics are likely to prove unsatisfactory and 
some stretching of the contracted parts is necessary in order to save 
time and make gymnastics more effective. To stretch these soft 
parts by gymnastic exercises is slow and often unsatisfactory, and 
when it is done must be accomplished by passive stretching, induced 
by pulling back the shoulders either with the arms at the sides or 
on a level with the shoulders, whichever position offers the greatest 
resistance. A padded roller, placed under the shoulders while the 
patient is lying on the back, furnishes an excellent fulcrum on 
which to make effective stretching of the arms and shoulders. 

An apparatus may be used in severe cases, especially where skilled 
gymnastic assistance is not available! 

The apparatus consists of an oblong gas-pipe frame of the ordinary pattern. 
Fastened to this near the middle, and hinged so as to be raised to any degree^ is 
another section of gas-pipe lying on the frame proper and of the same shape and 
size as the upper half of the frame. To this movable section is fastened, at right 
angles to it, and movable on it, a gas-pipe bridge rising about eighteen inches from 
the movable section (Fig. 171). 

When prepared for use two strips of webbing, lying one over the other, run 
from each of the buckles at the bottom of the frame. The lower two strips are 
tightly drawn, and run to the buckles at the end of the movable section. The 
upper two are loosely fastened to the bridge over the movable section. The 
cross-pieces are tightened and the patient laid face downward on the webbing 
strips, which may, if desired, have laid over them a folded piece of sheet wadding. 
The strips, however, even in adults, are not uncomfortable. The thighs are 
flexed and the feet rest on the floor, so that the lumbar spine is flattened. Two 
pieces of webbing are passed over the mid-dorsal region from side to side, tied to 
the lower non-movable frame on each side. These furnish the resistance for the 
straightening of the spine when the upper end of the frame is lifted, carrj'ing with 
it the head and upper chest. The upper part of the frame is lifted after the 
patient is in place and as much force as seems advisable is exerted. This should 
never be pushed beyond the point of mild discomfort. Several stretchings are 
first made of a few seconds each, and the movable part of the frame aixain let 
down to rest the patient. 



212 FAULTY ATTITUDE 

The use of corrective or retentive braces in round shoulders is often 
unsatisfactory because they are, as a rule, constructed only to pull 
the scapulae and arms backward, without making efficient forward 
pressure on the curved dorsal spine or making any marked improve- 
ment ^ in the general attitude. The "shoulder braces" sold in the 
instrument shops are notably unsatisfactory in most cases. 




Fig. 172. — Corset-waist for the Treatment of Round Shoulders. 

In flexible cases of moderate grade or in rigid cases of the same 
degree which have been made flexible, a properly constructed corset- 
waist to support the abdomen has, in the experience of the writer, in 
many cases proved more satisfactory than a brace in inducing an im- 
proved attitude. The abdominal element in these cases has been 
too much overlooked and the relaxed and stretched abdominal wall is 
a very important feature of the symptom-complex roughly called 
''round shoulders." 



TREATMENT 213 

Efficient abdominal support by means of a corset-waist not only 
enables the stretched abdominal muscles to shorten and recover 
tone, but by supporting the abdominal contents enables the patient 
to assume a better general position. A better position of the thorax 
at once becomes easier and the whole attitude is improved. 

Such corset-waists should fit tightest around the bottom just 
above the trochanters and should diminish in pressure from below 
upward, the upper part of the abdomen being free from constriction. 
They should button in front but be laced in the back, and from them 
may be hung skirts and stockings. 

There is no objection to their use in young children and the fear of 
the parents that they will "weaken" the abdominal wall will be dis- 
pelled as soon as the improved abdominal outline is seen after a short 
use of them. They should be used, of course, only in connection with 
and accessory to gymnastic treatment (Fig. 122). 

Corsets and Braces. — The use of supports to maintain the spine in 
a correct position is indicated— (i) in the case of children with lax 
muscles who are unable to hold an erect position between gymnastic 
treatments; and, (2) in resistant cases which are being stretched; 
but which cannot maintain between stretchings the improvement, 
secured by each one. In all of these the brace is to be regarded as a 
temporary measure, supplementary to the other treatment, whether 
gymnastic or mobilizing, and to be given up as soon as it can be 
dispensed with. As the sole treatment of resistant round shoulders 
the use of a brace, which by its corrective effect is to cure the mal- 
position, is more to be advised. The brace which, on the whole, 
is the most generally effective is the tempered steel upright support. 
It is made as follows: 

This form of apparatus consists of (a) a horizontal pelvic band, (b) two up- 
rights, and (c) a cross-bar. 

(a). The horizontal pelvic band encircles the posterior part of the pelvis from 
a point one inch posterior to the anterior superior spine on one side to a similar 
point on the other side. It is curved to fit the contour of the pelvis and should 
lie close against it. It is made of No. 15 gauge sheet steel, one and one-eighth 
inches wide. The uprights run from the posterior pelvic band along the sides 
of the spine to a point about on a level with the acromion process. At this point 
they are curved outward on the flat, on an angular turn, at an angle of forty-five 
degrees or more, and run upward and outward to a point just behind the anterior 
border of the trapezius. In this upper part they are curved to fit the contour of 
the shoulders and should lie flat against the skin when the axillary straps are 
tightened. 

(b). The uprights at their lower part are farther from each other than they are 
at the top. At the bottom their outer edges should be separated by a distance 



214 FAULTY ATTITUDE 

somewhat less than the distance between the two posterior superior spines. At 
the top they should lie over the transverse processes. They are made of No. i6 
gauge sheet steel, five-eighths of an inch wide, and shouM follow the outline 
of the back in general, but whatever correction is desired in the standing 
position is to be made by bending the uprights to fit the curve of the back in 
a corrected position rather than in the faulty position. 

(c). The cross-bar consists of a piece of steel, which in length should be one 
inch less on each side than the breadth of the body at the level where it is 
placed. It is riveted transversely to the uprights at a point just below the 
posterior fold of the axilla. The projecting ends beyond the bars should 
not rest on the scapulae, but if necessary, should be set backward by an 
angular curve to clear the scapulae. These are made of the same material as 
the uprights. 

Buckles are placed on the ends of the pelvic band, and the cross-bar and 
axillary straps are riveted to the upper ends of the uprights, one on each side. 
The brace is finished by being covered with leather, or by being nickel-plated, 
with leather covering to the front of the brace. The brace is attached to the 
body at the top by means of axillary straps and below by means of a broad 
belt of sheep-skin or cloth, which fits the abdomen and supports the lower 
part of it. 

Such a brace is worn continuously between exercise periods but 
not during the night. 

Summary of the Treatment of Round Shoulders. — Flexible cases are 
treated by gymnastics like postural scoliosis ; a corset-waist or brace 
may be necessary to maintain a correct position between treatments. 

Resistant cases must first be made flexible — (a) by gymnastics; (b) 
by manual stretching; (c) by stretching in apparatus; after which 
the problem is to maintain the improved position, just as in cases 
originally flexible. 



INDEX 



Acquired scoliosis, 102 

Age, 115 

Anatomy, 8, 26 

Arthritis deformans, 106-128 

Articular processes, 40 

Attitude, faulty, 194 

normal, 191 
Asymmetrical exercises, 147 
Average heights and weights, table, 72 Gymnastics, 134, 138 



False scoliosis, 53 
Faulty attitude, 194 
Flat back, 205 
Flexion of the spine, 30 
Forcible correction, 159 
Frequency of scoliosis, 70, 113, 116 
Functional scoliosis, 53 



Back, surface anatomy of, 26 
Bone, plasticity of, 47 
Bony rotation, 49 
Braces, 152, 155 

Cervicodorsal scoliosis, 66 
Cicatricial scoliosis, no 
Compound scoliosis, 67 
Congenital scoliosis, 99, 125 
Corrective jackets, 152-159 
Corsets, 152-155 
Creeping exercises, 151 
Curves, physiological, 11 

Diagnosis of round shoulders, 208 

of scoliosis, 125 
Diseases of the extremities, 107 
Dorsal scoliosis, 64 
Dorsolumbar scoliosis, 65 
Double curves, 50 

Elasticity of the spine, 21 

Empyema, no, 127 

Etiology of round shoulders, 205 

of scoliosis, 97 
Evolution of the spine, 20 
Examination for scoliosis, 71 
Exercises, asymmetrical, 147 

creeping, 151 

symmetrical, 142 



Habit scoliosis, in 
Habitual scoliosis, 61 
Heart disease, no 
History of scoliosis, i 
Hyperextension of the spine, 32 
Hysterical scoliosis, 109 

Identification of vertebrae, 27 
Inclination of pelvis, 24 
Infantile paralysis, 107, 126 
Intervertebral discs, 10, 88 
Ischias Scoliotica, 109 

Jackets, removable, 172 

Kyphoscoliosis, 65 

Lateral corrective pressure, points for, 

28 
Lateral flexion of spine, 32 
Ligaments of the spine, 12, 88 
Lumbar scoliosis, 62 

Mechanism of scoliosis, 43, 58 
Movements of the spine, 29 

conclusions of, 41 
Muscles of the spine and thorax, 16. 
27, 89 

Nerve supply, 19 
Nervous diseases, 107 



2l6 



INDEX 



Normal attitude, 194 
examination of, 73 

Occupation scoliosis, iii 
Occurrence of round shoulders, 207 

of scoliosis, 112 
Operative treatment, 189 
Organic scoliosis, 61 
Organs, internal, pathology of, 94 
Ossification of the spinC; 20 
Osteomalacia, 106 



Paralytic scoliosis, 126 
Pathology of round shoulders, 207 

of scoliosis, 8s 
Pelvic inclination, 24 
Pelvis, asymmetry of, 93, 102 

obKquity of, 102 
Photography in scoliosis, 79 
Physiological curves, 11, 21 
Phthisis, no 
Planes of the body, 21 
Plaster jackets, corrective, 159 
Plasticity of bone, 47 
Points for lateral corrective pressure, 2' 
Postural scoliosis, 53 
Prognosis of round shoulders 209 

of scoliosis, 129 

Quadruped scoliosis, 112 

Rachitic scoliosis, 104, 125 
Record of scoliosis, 79 
Removable jackets, 172 
Retrotorsion, 56 
Reverse rotation, 56 
Rickets, 104-125 
Rotation, bony, 49 
of the spine, s^ 
Round back, 200-203 

hoUow back, 200-203 
shoulders, 200 
diagnosis, 208 
etiology, 205 
occurrence, 207 
pathology, 207 
prognosis, 209 
treatment, 209 
upper back, 204 



Sacro-iHac articulation, 13 
School fatigue, 118 

furniture, 119 

life, 118 
Schulthess' measuring apparatus, 82 
Scoliosis, acquired, 102 

cervicodorsal, 66 
Scolosis, compound, 67 

congenital, 99, 125 

description, 51 

dorsal, 64 

dorsolumbar, 6$ 

examination for, 71 

false, 53 

from asymmetries, 102 

from cicatrices, no 

from empyema, no, 127 

from heart disease, no 

from malformations of^^vertebral 
column, 99 

from malformations of scapula 
and thorax, loi 

functional, 53 

habit, III 

habitual, 61 

history of, i 

hysterical, 109 

in quadrupeds, 112 

lumbar, 62 

mechanism of, 43, 58 

occupation, in 

organic, 61 

paralytic, 107 

pathology of, 83 

postural, 53 

prognosis, 129 

rachitic, 104, 125 

record of, 79 

relation to school life,»ii7 

structural, 61-129 

symptoms, 51 

terminology, 52 

total, 53 

transitional, 57 

types of, 48 
Sex, 114 
Short leg, 102 

Shoulder girdle, pathology, 93 
Side bending of the spine, 32 



INDEX 



217 



Spastic paralysis, 108 
Spinal ligaments, 12 

movements, 29 

muscles, 16, 27 
Sternum, 15, 92 

Stretching of spine, passive, 154 
Structural scoliosis, 61-129 
Surface anatomy of back, 26 
Symmetrical exercises, 142 
S3anptoms of scoliosis, 51 

Terminology, 52 
Thorax, 13, 90 

anatomy of, 8 

muscles of, 16 

shape and boundaries of, 15 
Torsion, reasons for, 38 
Torticollis, 102 
Total scoliosis, 53-129 
Tracings in scoliosis, 81 
Transitional scoliosis, 57 



Treatment of postural scoliosis, 131 
of round shoulders, 209 
of structural scoliosis, 127-133 

Treatment, operative, 189 

True scoliosis, 61 

Tuberculosis of spine, 106-128 

Types of scoliosis, 48 

Unequal hearing, 104 

vision, 104 
Upright position, defects of, 44 

mechanics of, 43 

Varieties of structural scoliosis, 62 
Vertebrae, changes in, 85 

identification of, 27 

pathological affection of, 104 
Vertebral column, anatomy of, 8 

Wolf's law, 47 
Writing position, 120 

X-ray in scoliosis, 77 



